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[New York] Observation service billing: review CMS requirements before
Effective date
Sep 1, 2026
Identified
Aug 2, 2026
Summary
Effective September 1, 2026, Anthem Medicare Advantage in New York is updating observation service billing requirements to align with CMS guidance for POS codes 19, 22, and 23. Key changes: only one initial observation service code per patient visit, only one observation code per calendar date per billing practitioner, and only the ordering/overseeing physician may bill observation codes—consultants must use appropriate outpatient service codes instead.
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What to do
Action · 10 steps
01Before September 1, 2026: Billing team must implement the following controls in the billing system and provider communication.
02Configure system to reject claims with multiple observation service codes billed on the same calendar date per practitioner.
03Require that only one initial observation service code is submitted per patient visit.
04Implement validation to ensure only the ordering physician bills observation codes, and that consulting practitioners use appropriate outpatient service codes instead.
05Update billing instructions and encounter forms to communicate these requirements to all providers.
06Train billing staff to identify and correct observation billing errors before submission.
07Notify all participating providers in writing of these requirements.
08After September 1, 2026, claims that violate these requirements will be subject to denial.
09Monitor submitted claims for compliance and work with providers to correct non-compliant patterns.
10Document all communication to providers regarding this change.
Original notice
[New York] Observation service billing: review CMS requirements before
providernews.anthem.com · Always check the source before changing claims.
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