By Carol Hoppe, CPC, CCS-P, CPC-I
MedLucid Solutions, LLC
The ISMA has had numerous conversations with ISMA members regarding Anthem BCBS’s new automated review program for level 4 and 5 Evaluation and Management (E/M) services.
We were notified on Oct. 19 that Anthem has suspended this program until Jan. 1, 2022, based on the backlog of appeals they have received to date.
This “E/M Leveling Program” (aka downcoding) was announced by Anthem in its August 2020 newsletter in response to perceived overcoding of level 4 and 5 visits. In June of 2021, the ISMA started hearing from many physician practices who were seeing a significant number of claims downcoded. The ISMA gathered information and presented a list of questions to Anthem on a phone call with its executive team on Aug. 12, 2021. During that call, Anthem stated the following.
Selection process
The E/M Leveling Program is one of Anthem’s initiatives to address perceived provider overcoding. E/M coding represents the largest category of codes submitted by most providers, and monitoring for compliance with billing remains an ongoing effort for Anthem. Typically, Anthem’s provider education department looks for providers who are billing higher-level visits than their peers. Letters are sent to each “outlier” with their Anthem representative’s name and phone number included so providers can call with any questions or concerns. If no change in coding patterns occurs, the provider may be placed on prepayment review. This is a very manual and laborious process, where providers must submit documentation before the claims are processed or paid.
The new E/M Leveling Program is an automated process that looks at what E/M level providers in like specialties are billing to manage a certain condition. Every diagnosis code has been cross-walked to the most common level of service providers are billing for patients with like conditions, based on risk-adjustment coding models. Not every level 4 or 5 claim is impacted. This process identifies providers with a history of billing E/M services at significantly higher levels compared to their peers with similar risk-adjusted members. This program also includes E/M services in the hospital and emergency room, with only the highest level of inpatient coding being impacted (codes 99223 and 99233).
When claims are submitted, Anthem’s proprietary software looks at every diagnosis on the claim. “Without medical record documentation, Anthem believes this automated process more closely represents the new 2021 coding guidelines for office and other outpatient service codes 99202-99215, because the diagnosis is the most closely related data on a claim to represent medical decision making (MDM),” said Jay DeLaRosa, Anthem’s reimbursement policy manager. This automated process allows certain claims to pay rather than waiting on supporting documentation to be submitted. Anthem believes this approach is more advantageous for providers than prepayment review, where delays in payments occur and could result in no payment at all if documentation is never submitted for review.
The E/M Leveling Program does not replace Anthem’s existing prepayment review program. Providers currently under Anthem’s prepayment review program will be excluded from the E/M Leveling Program. Providers in the E/M Leveling Program are reviewed every 6 months, at which point a provider may be removed from the program or may be moved to some other program.
There is no list of diagnosis codes Anthem would provide for conditions that only meet a level 3 service. All diagnosis codes on the claim are considered, and comorbidities are also reviewed on any second level of appeal, according to Chris Corvino, who oversees Anthem’s medical coding activities. Providers are instructed to use ICD-10-CM codes to the highest level of specificity based on the conditions that are addressed at each visit; Anthem does not expect providers to level their claims based on diagnoses.
Guidelines being used by Anthem
The 2021 guidelines for office and other outpatient E/M services (99202-99215) are used to evaluate all office and outpatient claims on appeal. The 1995 or 1997 guidelines are used for all other E/M services. Anthem recognizes that there are instances where time may be warranted when documented; however, Anthem will give credit for the highest level supported by documentation.
Reason codes being used
The only remittance code used to reference these service level adjustments should be CO-186. While some practices have also noticed CO-45 applied to downcoded claims, this typically refers to contractual adjustments making it difficult for practices to track on reports. Anthem stated that there was a system glitch which they believe has been resolved and all claim adjustments for this reason should now be identified with CO-186. Practices that continue to see CO-45 on downcoded services should notify Rissa Herndon
here, so she can investigate and resolve any errors.
Practices have noticed comments on appealed claims that state, “The documentation did not support the level of service based on History, Exam and/or Medical Decision Making”, which appears to contradict 2021 E/M guidelines. This is because Anthem has only one standard remittance explanation for both office and outpatient codes 99202-99215 and all other E/M codes (still based on History, Exam and MDM). Anthem’s goal is to add comments to their system that will explain when documentation does not meet the level of service based on the 2021 E/M guidelines including 1) Problems Addressed, 2) Data Ordered or Reviewed, and 3) Risk of Treatment Options.
What you can do
DeLaRosa stated that approximately 6% of all providers will be impacted by this new leveling program. Those who appeal 100% of their claims are seeing very few overturned; however, those who review the documentation before submitting an appeal and provide justification for the level of service have a greater chance of seeing the decision overturned. If any practice wants to do a “deep dive” and have further discussions with Anthem on why they believe the levels are not supported by documentation, Anthem is willing to meet with providers and go through examples together. Please contact your Anthem provider experience representative if you are interested. If you have not received a timely response from your rep, please contact Jacqueline Marsalis, director of provider experience for Indiana,
here.
If your practice’s experiences are inconsistent with the information ISMA was provided by Anthem as summarized in this article, or if you are not successful in working with Anthem to resolve any issues, please contact ISMA’s practice management consultant, Carol Hoppe,
here. ISMA has regular meetings with Anthem and will be happy to take additional questions and concerns to them.