Medicare AdvantageAdministrativeHigh impact
[Virginia] Telehealth claims update: ICD-10-CM Excludes1 editing
Anthem BCBS·VA·Coding
Effective date
Sep 1, 2026
We identified it
Jul 21, 2026
Summary
Beginning September 1, 2026, Anthem Blue Cross Blue Shield and HealthKeepers will enforce ICD-10-CM Excludes1 editing rules on telehealth claims (POS 02 and POS 10) to match requirements applied to other claim types. Claims with diagnosis code combinations prohibited by Excludes1 notes may be denied for reimbursement. Providers must verify diagnosis codes comply with Excludes1 conventions before submission.
Action Required
Before September 1, 2026: (1) Billing team and providers must implement processes to review ICD-10-CM Excludes1 notes before submitting telehealth claims with POS 02 or POS 10. (2) Update EMR/billing software to flag or prevent submission of diagnosis code combinations that violate Excludes1 conventions. (3) Training: Educate all clinical staff and coders on Excludes1 rules and the requirement to code to the highest level of specificity with supporting documentation. (4) Establish dispute resolution process: designate staff to submit claims disputes through Availity.com or Provider Dispute Resolution Form if Excludes1 claim denials appear inconsistent with ICD-10-CM guidance. (5) Audit current telehealth billing workflows for high-risk diagnosis code combinations (e.g., Z01.419 with Z12.4). Consequence: Claims submitted with prohibited diagnosis code combinations will not be eligible for reimbursement under Medicare Advantage and Medicaid plans.