← Back to list
Important Coding and Documenting Information from Risk Management
Act
immediately
Effective date
Not stated in the notice
Identified
Oct 3, 2026
Summary
This is a risk management guidance document emphasizing that accurate, specific documentation in the assessment/plan section is required for all diagnoses to be coded and reported on claims. The policy clarifies that conditions must be actively monitored, evaluated, assessed, and treated during the encounter (MEAT framework) to be billable—simply listing them in problem lists or history/physical is insufficient. Up to 12 diagnoses per claim can be reported when properly documented.
Get alerts when payers change rules like this one
We check Horizon BCBS NJ and other payers every day and email you when a change matches your specialty and state.
Get Horizon BCBS NJ alertsPolicy Monitoring is free. No card required.
What to do
immediately · 7 steps
01Providers and billing team must implement the following changes.
02Audit all encounter templates and EHR documentation forms to ensure the assessment/plan section is the primary location for diagnosis documentation, not problem lists or H&P alone.
03Train all clinical staff and providers on the MEAT framework—diagnoses must show evidence of Monitoring, Evaluation, Assessment, and Treatment in the current encounter to be coded and billed.
04Update billing software validation rules to cross-reference documentation: claims should only include diagnoses that appear in the assessment/plan with corresponding clinical evidence (test results, medication changes, therapy orders, or documented clinical assessment).
05Implement a compliance checklist for billers: before submitting claims, verify (a) all diagnoses are documented in assessment/plan, (b) no unconfirmed diagnoses (probable, possible, suspected) are coded, (c) status conditions (transplant, amputation, dialysis, chemotherapy) are documented at least annually, (d) all diagnoses codes match medical record documentation, and (e) medical records are signed.
06Stop coding conditions that are no longer being treated or monitored—diagnoses do not carry over between visits or years.
07Audit submitted claims for the past 90 days to identify and correct any claims with improperly documented or unsupported diagnoses; resubmit corrected claims.
If missed: Failure to comply will result in claim denials, compliance violations, and potential recovery actions from payers.
Original notice
Important Coding and Documenting Information from Risk Management
horizonblue.com · Always check the source before changing claims.