Medicare AdvantageBilling CodesHigh impact
[Georgia] Observation service billing: review CMS requirements before
Anthem BCBS·GA · Emergency Medicine, Internal Medicine, General Practice·Claims & Billing
Effective date
Sep 1, 2026
We identified it
Aug 3, 2026
Summary
Effective September 1, 2026, Anthem Blue Cross and Blue Shield (Georgia) is updating observation service billing requirements to align with CMS guidance for claims billed under POS codes 19, 22, or 23. Key restrictions include: only one initial observation service code per patient visit, one observation code per calendar date per billing practitioner, and only the ordering/overseeing physician may bill observation codes—other practitioners must use appropriate outpatient service codes instead.
Action Required
By August 31, 2026: Billing team must review and update observation service billing practices to comply with CMS requirements. Specifically: (1) Configure billing system to prevent submission of multiple initial observation codes per patient visit; (2) Implement control to block multiple observation service codes per calendar date per practitioner; (3) Update provider education and billing guidelines to clarify that only the physician ordering and overseeing observation care may bill observation codes; (4) Train providers and billing staff that consulting physicians and other practitioners during observation stays must bill appropriate outpatient service codes instead; (5) Audit recent claims (past 6 months) for observation services under POS 19, 22, or 23 to identify potential billing violations. Ensure all participating providers understand the prohibition on balance billing members under this update. All claims submitted after September 1, 2026 that violate these requirements will be subject to denial and potential recovery.