MedicaidBilling CodesHigh impact
Cotiviti EM Leveling Effective 7/15/2026
Ambetter·SC·Coding
Effective date
Jul 15, 2026
We identified it
Aug 26, 2026
Summary
Effective 7/15/2026, Absolute Total Care (Cotiviti) will implement an E&M leveling program that reviews and recodes high-level Evaluation and Management services based on diagnostic information and CMS/AMA guidelines. Providers must ensure E&M documentation aligns with CPT Manual and CMS Documentation Guidelines for E&M services, or claims may be downleveled to lower reimbursement rates.
Action Required
Before 7/15/2026: (1) Billing and Clinical Teams must review AMA CPT Manual and CMS Documentation Guidelines for Evaluation and Management services to understand E&M code selection criteria; (2) Providers must audit current E&M coding practices and ensure documentation supports the E&M level billed—specifically for high-level codes (99214, 99215, 99213, etc.)—as claims will be reviewed and potentially downleveled based on diagnostic information and peer risk adjustment; (3) Update EMR templates and encounter forms to prompt providers for complete documentation of medical decision-making, history, and examination components that justify E&M level selection; (4) Establish internal monitoring process to identify high-coding practitioners and provide targeted education. Failure to comply will result in claim recoding to lower E&M levels and reduced reimbursement.