CommercialDocumentationHigh 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
Oct 6, 2026
Summary
Effective March 1, 2026, Providence Health Plan and Providence Health Assurance will conduct targeted audits of practitioners billing high-level E&M services at frequencies significantly greater than peers in similar specialties. Unsupported high-level E&M claims may be subject to recoupment; Providence will provide education when disproportionate billing is identified.
Action Required
Starting March 1, 2026: Billing team and providers should review E&M coding practices to ensure high-level E&M services (99214, 99215, 99224, 99225, etc.) are billed only when supported by clinical documentation that meets applicable guidelines. Monitor for outreach from Providence Health Plan regarding audit findings on billing patterns; if contacted about disproportionate high-level E&M billing, respond with clinical justification and documentation. Providers should confirm that encounter documentation supports the E&M level billed to reduce recoupment risk. Billing team should implement internal audits of high-level E&M claims to identify potential documentation gaps before Providence's targeted audits occur.