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Dr Santosh Guptha

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Medical coder reviewing E/M claim audit alerts and payer policy updates for Anthem Blue Cross 2026

Medical Coders Alert: Anthem’s E/M Policy Could Change Everything

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Expert insights from Dr Santosh Guptha, CEO Medesun, bringing 21 years experience, 45 certifications, world record holder in medical coding and billing. Anthem Blue Cross E/M Policy 2026: Why Medical Coders Must Pay Attention Now A Major E/M Policy Change Is Coming — And It Impacts Coders Directly Medical coders and billers should be on high alert. The California Medical Association (CMA) has formally urged Anthem Blue Cross to rescind a newly announced Evaluation and Management (E/M) claim review policy scheduled to take effect on February 15, 2026. CMA warns that the policy could lead to improper downcoding, delayed payments, and a significant increase in administrative burden for physician practices. For medical coders, this policy is not just a payer update — it is a workflow, compliance, and revenue integrity issue. What Is Anthem’s New E/M Claim Review Policy? According to Anthem’s November 13 provider notice, physicians who are identified […]

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“New rules in lab tests billing 2026 CMS explained for medical coders and billers by Medesun Medical Coding Academy”

2026 CMS Lab Billing Changes Every Medical Coder and Biller Must Understand

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Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) finalized major updates to the Clinical Laboratory Fee Schedule (CLFS) that are changing how laboratory services are billed across the United States. For years, many lab-related services were bundled—the cost of collecting a specimen was quietly included in the price of the test itself. In 2026, CMS has moved toward a specimen-first, unbundled billing model. The result? More line items on lab bills, even when the visit itself hasn’t changed. 1. Specimen Collection Fees Are Now Separately Payable (36415 & G0471) One of the most visible 2026 changes is the expanded use of separately payable specimen collection codes. Under the CY 2026 CLFS Annual Update, CMS now allows distinct payment for: 36415 – Routine venipuncture G0471 – Collection of a specimen from a single patient by a laboratory Previously, the labor, supplies, and staff time required to collect […]

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Medical Coding Jobs

ASC Coding in 2026 New Opportunities for Outpatient Coders

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On Nov 21, CMS finalized the 2026 Hospital Outpatient Prospective Payment System OPPS and Ambulatory Surgical Center ASC rule The rule focuses on Expanding outpatient care Reducing inpatient only services Improving hospital price transparency Strengthening safety and accountability These changes increase workload and job demand for coders billers auditors and compliance teams Hospital Outpatient and ASC Changes CMS is phasing out the inpatient only list over three years In 2026 285 procedures removed from the inpatient only list 289 procedures added to the ASC covered list Most procedures are musculoskeletal and surgical Medicare can still pay for these procedures in hospital outpatient departments when clinically appropriate Impact More surgeries will shift to outpatient and ASC settings Higher demand for OPPS APC coding skills Increased focus on medical necessity documentation CMS continues the two midnight policy review exemption for procedures removed from the inpatient only list This remains in place until […]

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Medical Coding Jobs

The Great Outsourcing Wave: How CMS 2026 Policies Boost Indian Medical Coding and RCM Jobs

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The year 2026 is a defining milestone for the global healthcare industry. Major policy reforms in the United States related to reimbursement, audits, prior authorization, risk adjustment, price transparency, and artificial intelligence are reshaping how healthcare organizations function. While these changes increase compliance pressure for US providers, they create massive long term opportunities for India, especially for skilled medical coders and billers. For professionals trained through MEDESUN, this transition represents career stability, higher salaries, and global relevance. Increased Outsourcing of US Medical Coding and Billing to India As US healthcare providers face rising compliance costs and stricter regulations, outsourcing has become a strategic necessity. India continues to be the preferred global destination for US healthcare revenue cycle management services. Indian teams are increasingly handling High volume US medical coding Backlog and audit clean up projects HCC and risk adjustment coding Prior authorization and utilization review Denial management and appeals India […]

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Colonoscopy Coding

Colonoscopy Screening Coding Essentials – Expert Insights by Dr. Santosh Kumar Guptha

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Screening and diagnostic colonoscopy services remains a high risk and high impact area for providers, ASCs, and billing teams. With audits increasing and payer scrutiny tightening, coders must clearly understand the distinction between average risk screening, high risk screening, and diagnostic colonoscopy. What Is Screening Colonoscopy Screening colonoscopy is performed on a patient without signs or symptoms of colorectal disease. The purpose is early detection and prevention, not diagnosis of an existing condition. According to Medicare guidelines published by the Centers for Medicare and Medicaid Services CMS, an average risk patient is defined as one who has No personal history of adenomatous polyps No family history of colorectal cancer No history of inflammatory bowel disease For average risk Medicare beneficiaries, screening colonoscopy is reported using G0121 for Medicare 45378 for commercial insurance Medicaid exchange marketplace plans and TRICARE An appropriate ICD 10 CM screening diagnosis code must be linked to […]

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AI Medical Coding

Cleveland Clinic’s AI Coding Move and What It Means for Medical Coders – Insights from Dr. Santosh Guptha, Medesun

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Cleveland Clinic partnered with Akasa to deploy AI tools within mid-revenue cycle workflows, where patient care documentation is translated into standardized medical codes for: Billing Reporting Continuity of care According to system leadership: Coders may review 100+ clinical documents per encounter They choose from more than 140,000 ICD-10, CPT, and HCPCS codes Manual coding can take up to one hour per case The AI solution helps: Automate routine, repetitive coding tasks Identify which steps can be automated Flag cases that require human judgment and clinical reasoning Early results showed improved speed and accuracy, smoother prior authorizations, fewer delays in care, and a better patient experience. The Key Insight: AI Does Not Replace Coders — It Redefines Them What Cleveland Clinic clearly demonstrated is this: AI handles volume and repetition. Humans handle judgment, compliance, and accountability. AI can: Scan documentation faster Suggest codes Detect patterns But AI cannot: Interpret nuanced clinical […]

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Medical Coding

Medical Coding Errors Will Now Be Public – The Price Transparency Shock

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Healthcare in the United States is entering a new phase of transparency and accountability. With renewed efforts by the Trump Administration to strengthen insurer price transparency requirements, healthcare prices are expected to become clearer, more accurate, and more actionable for patients and employers. While this change is designed to empower consumers, it also has a direct and significant impact on the medical coding industry. For medical coders, this is not a threat — it is a major opportunity. What Is Price Transparency and Why It Matters Price transparency rules require health insurers and providers to publicly disclose negotiated rates for medical services. These prices are published using machine-readable files that are directly linked to CPT and ICD-10 codes. In simple terms, the price a patient sees online is only as accurate as the medical code behind it. As transparency rules become stricter and enforcement increases, errors that were once internal […]

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Neurology Coding

FIMC® Neurology Coding by PMBAUSA – Mastering High-Risk Surgical Coding

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Neurosurgery stands at the intersection of clinical complexity, high financial risk, and intense regulatory scrutiny. It is consistently identified by CMS, commercial payers, and the Office of Inspector General OIG as one of the highest-risk medical specialities due to high reimbursement values, technically complex procedures, and frequent documentation gaps. For medical coders, this makes neurosurgery not just another speciality—but a true test of advanced coding expertise. The FIMC®-Neurosurgery Coding Course is purpose-built to prepare medical coders for this challenge. This advanced, fellowship-level program goes far beyond basic CPT and ICD-10 knowledge. It trains coders to think like auditors, interpret operative reports like surgeons, and apply payer rules with precision. Participants gain a deep understanding of diagnosis-driven coding, global surgery rules, modifier discipline, and bundling compliance, all of which are critical to surviving and succeeding in neurosurgery billing environments. In an era where OIG audits focus heavily on medical necessity, improper […]

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SNF Coding

Skilled Nursing Facility SNF Coding Course by PMBAUSA LLC

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Skilled Nursing Facility SNF coding is one of the most important and high demand areas in US healthcare medical coding today. With the aging population and increasing need for post acute care, SNFs play a critical role in patient recovery and continuity of care after hospital discharge. In medical coding, SNF stands for Skilled Nursing Facility. It is a licensed healthcare setting that provides short term skilled nursing care and rehabilitation services to patients recovering from hospitalization, illness, injury, or surgery. These services are typically provided under Medicare Part A and require strict documentation and accurate coding to ensure compliance and proper reimbursement. What is a Skilled Nursing Facility A Skilled Nursing Facility is a facility or part of a facility that provides skilled nursing care and related services. Patients admitted to an SNF require ongoing medical or nursing care or rehabilitation services that cannot be safely provided at home. […]

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Basics of Neurosurgery Coding – ICD-10-CM

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Neurosurgery diagnoses are mainly coded from: o Chapter 6 (G00–G99): Diseases of the Nervous System o Chapter 13 (M00–M99): Musculoskeletal system (spine-related conditions) o Chapter 19 (S00–T88): Injuries & trauma (head injury, spinal trauma) • Always identify whether the condition involves: o Brain o Spinal cord o Peripheral nerves • Laterality (right, left, bilateral) is critical, especially for: o Brain lesions o Spinal nerve involvement • Differentiate acute vs chronic neurosurgical conditions • Common neurosurgery-related diagnoses: o Brain tumors (benign vs malignant, primary vs secondary) o Intracranial hemorrhage o Hydrocephalus o Herniated intervertebral discs o Spinal stenosis o Traumatic brain injury (TBI) • Use sequela codes for late effects of brain or spinal injuries • Identify underlying cause vs manifestation (e.g., tumor causing hydrocephalus) • In inpatient cases, capture CC/MCC conditions impacting MS-DRGs • Assign Z codes when applicable (history of brain surgery, devices) ________________________________________ Basics of Neurosurgery Coding – […]

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