MedicaidAdministrativeHigh impact
[Ohio] E/M services correct coding
Anthem BCBS·OH·Coding
Effective date
Aug 1, 2026
We identified it
May 3, 2026
Summary
Effective August 1, 2026, Anthem Blue Cross and Blue Shield Medicaid (Ohio) will implement automated analytics to review E/M service coding levels on selected claims. Providers identified as coding at higher E/M levels than risk-adjusted peers will have claims reviewed pre-payment, with potential adjustments to lower supported levels, denials, or claim holds pending documentation. Providers must ensure E/M coding strictly adheres to AMA CPT guidelines and CMS standards based on medical decision-making complexity or time.
Action Required
Before August 1, 2026: (1) Billing team must audit current E/M coding patterns across all claims to identify potential outlier coding at levels 4-5 compared to peer patterns. (2) Providers and clinical documentation staff must review and strengthen medical record documentation to clearly support the medical decision-making complexity and time spent for each E/M level billed. (3) Implement or update internal compliance protocols requiring providers to code E/M services strictly in accordance with current AMA CPT manual and CMS E/M guidelines—do not code above the complexity level actually supported by clinical documentation. (4) Establish a process to track and respond to pre-payment claim holds and denials; designate staff to submit medical record documentation through the dispute resolution process via Availity Chat with Payer if claims are adjusted downward. (5) Monitor claims post-August 1 for denials or adjustments; practices identified as outliers should expect increased E/M claim review. Failure to comply may result in claim denials at submitted E/M levels and reimbursement adjustments to lower supported levels.