FIMC-EM

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.

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What Is Anthem’s New E/M Claim Review Policy?

According to Anthem’s November 13 provider notice, physicians who are identified as billing higher-level E/M codes compared to peers with similar risk-adjusted patients will be subjected to additional claim scrutiny.

Key concern for coders:
The review appears to rely only on claim-level data, not full medical record review.

Claims flagged under this policy may be:

• Automatically downcoded to a lower E/M level

• Suspended until medical records are submitted

• Rejected for reimbursement unless resubmitted at a lower E/M level

This directly places coding accuracy, documentation quality, and E/M defensibility under the microscope.

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Why Medical Coders Should Be Concerned

1. Lack of Transparency Creates Coding Risk

CMA states that Anthem has not clearly disclosed:

• Which E/M codes are affected

• What benchmarks or algorithms define “higher than peers”

• How the “appropriate” E/M level will be determined

Without transparency, coders cannot predict payer behavior, making clean-claim submission more difficult.

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2. Conflict With National E/M Coding Standards

This is a critical point for coders.

Since 2021, E/M levels are determined by:

• Medical Decision Making (MDM), or

• Total Time spent on the date of service

These standards are defined by:

• AMA CPT® guidelines

• CMS E/M rules

Automatic downcoding without reviewing the medical record ignores these rules and undermines the E/M framework coders are trained to follow.

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3. Increased Denials, Appeals, and Rework

From a revenue cycle perspective, this policy could:

• Increase medical record requests

• Delay claim payments

• Drive up appeals and rework

Industry data shows:

• $40–$75 cost to providers per appealed claim

• $50–$150 cost to payers per appeal

For coders, this means more follow-ups, more corrections, and more pressure — without added reimbursement.

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What CMA Is Asking Anthem to Do

CMA is urging Anthem to:

• Rescind the policy before Feb. 15, 2026

• Replace broad penalties with targeted education

• Collaborate with identified outliers instead of applying blanket claim actions

The message is clear:
Educate, don’t penalize. Audit with transparency, not algorithms alone.

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What Medical Coders and Billers Should Do Now

Immediate Action Steps

Medical coders should:

• Strengthen E/M documentation reviews, especially MDM elements

• Ensure time-based coding is clearly supported when used

• Prepare for payer scrutiny driven by analytics, not charts

• Educate providers on clear MDM risk, data, and complexity language

• Track Anthem-specific denials and downcoding trends

• Ensure hire skilled medical coders who has undergone best medical coding training

This policy reinforces a reality coders must accept:

E/M coding is no longer just about guidelines — it is about defensibility.

The Anthem E/M policy controversy highlights a growing trend:
Payers are using peer comparison and claim analytics to drive reimbursement decisions.

For medical coders, success in 2026 and beyond will depend on:

• Deep understanding of E/M MDM rules

• Audit-ready documentation

• Payer-specific compliance awareness

• Proactive education, not reactive appeals

Coders are no longer just code assigners —
they are becoming revenue protection and compliance professionals.