Medicare AdvantageDocumentationHigh impact
Special Alert February 2026 - E&M Correct Coding - New and Existing E&M Codes
Providence Health Plan·OR·Coding
Effective date
Mar 1, 2026
We identified it
Sep 2, 2026
Summary
Starting March 1, 2026, Providence Health Plan will conduct targeted audits on E&M coding to identify practitioners billing high-level E&M services at disproportionately higher rates than their specialty peers. Unsupported high-level E&M claims may be subject to recoupment. Providers should ensure clinical documentation supports the E&M level billed.
Action Required
By March 1, 2026: (1) Billing team and providers must review current E&M billing patterns and ensure all high-level E&M services (99213-99215 for established patients, 99201-99205 for new patients) are fully supported by clinical documentation in the medical record. (2) Providers should document medical necessity, history, examination, and medical decision-making consistent with the billed E&M level. (3) Billing team must audit encounter templates and EMR documentation requirements to verify they prompt providers to document elements supporting the claimed E&M level. (4) Establish internal monitoring to track E&M billing levels by provider and specialty to identify outliers before Providence audits. Failure to maintain adequate clinical documentation will result in claim recoupment by Providence Health Plan.