CurrentAnthemPolicy C-09007

Documentation and Reporting Guidelines for Evaluation and Management (E/M) Services - Professional

Defines Anthem's reimbursement and documentation requirements for professional Evaluation and Management services for commercial lines, aligning with CMS guidelines for selecting E/M levels by time or Medical Decision Making (MDM), and applies to providers submitting claims to the health plan unless superseded by contracts or mandates.

Policy Summary

PayerAnthem

PolicyDocumentation and Reporting Guidelines for Evaluation and Management (E/M) Services - Professional

Policy CodePolicy C-09007

Change TypeDefinitions clarified

Effective Date07/01/2026

Next Review Date

Key ActionWhen using time to report E/M codes, document the exact time, medical appropriateness, and a descriptive narrative of activities, and ensure MDM elements are fully documented to support the billed E/M level.

SourceLink

POLICY UPDATE CHANGES

Updated Definitions section for clarity effective 07/01/2026 per 04/01/2026 review.

Follows 2021MDM framework used to select E/M level

AllowedTime as basis for E/M level

2026-07-01Policy effective date

C-09007Internal identifier

Policy Summary & Scope

This policy defines Anthem's reimbursement and documentation requirements for professional Evaluation and Management (E/M) services for commercial lines and applies to providers submitting claims to the health plan unless superseded by provider, state, federal contracts or mandates. The health plan follows CMS guidance for selecting E/M levels by time or Medical Decision Making (MDM), and requires that time-based coding include an exact time supported in the medical record and that MDM-based coding be supported by documentation of the assessment/diagnosis, status of presenting problems, data reviewed, and risk considerations in accordance with the 2021 AMA CPT Level of MDM Table.

Overview

MDM framework used to select E/M levelFollows 2021 AMA CPT Level of MDM Table

Time as basis for E/M levelAllows time-based coding for E/M when documentation requirements met

Policy effective dateEffective 2026-07-01

Internal identifierPolicy number C-09007

Documentation & E/M Selection Criteria

Documentation requirements when time is used to select E/M level

When reporting E/M codes based on time, documentation must meet all listed elements; otherwise the claim will be evaluated using MDM.

ALL of the following

Provide an exact time of service (not an approximate range) supported in the medical record.
Support the medical appropriateness of the visit.
Document a description of individual activities performed for that specific encounter (not just a list of allowed elements).
Document the activities performed during the stated time.

MDM documentation requirements

For services billed using Medical Decision Making (MDM), the medical record must include the following elements to support the complexity and appropriateness of the billed E/M level.

ALL of the following

An assessment, clinical impression, and/or diagnosis for each encounter (may be explicit or implied by management decisions).
Presenting problems addressed in history, physical exam (if applicable), and MDM.
For established diagnoses: documentation of status (improved, well controlled, resolving/resolved OR inadequately controlled, worsening, or not changing as expected).
For problems without established diagnosis: assessment may be differential diagnosis or probable/possible/'rule out' diagnosis.
Documentation of initiation or change in treatment when applicable.
If referrals/consultations occur, documentation must indicate to whom or where the referral/consultation is made or from whom advice is sought.

Selecting level of MDM

Level of MDM is determined using the 2021 AMA CPT Level of MDM Table considering three elements.

ALL of the following

Number and complexity of problems addressed during the encounter.
Amount and/or complexity of data to be reviewed and analyzed.
Risk of complications and/or morbidity or mortality of patient management options.

Required Documentation & Billing Actions

Documentation Required

Document exact time when using time to select E/M level

When time is used to report E/M codes, document exact time supported in the medical record, medical appropriateness, and a descriptive narrative of the activities performed during that time.

Documentation Required

Document MDM elements

Ensure the record includes an assessment/clinical impression or diagnosis for each encounter; status of presenting problems; initiation or change in treatment; referrals or consultations (including to whom); diagnostic orders; review of tests; and relevant findings from prior records or additional history as applicable to support the selected MDM level.

Billing Rule

Claims may be re-evaluated if documentation insufficient

If documentation requirements for time or MDM are not met, Anthem will evaluate the claim using the alternate method (for example, use MDM if time documentation is insufficient) and may reject, deny, or recover payment if coding/billing guidelines are not followed.

Context & References

This policy aligns Anthem requirements with CMS rules and CPT changes, including adoption of the 2021 AMA CPT Level of MDM Table and updates reflecting the CMS Final Rule. References considered in developing the policy include: CMS Final Rule, 2023 (87 FR 69404); CMS Medicare Learning Network (MLN); 1995 and 1997 Documentation Guidelines for E/M Services; Optum EncoderPro, 2025; and Current Procedural Coding Expert: AMA CPT Evaluation and Management (E/M) Services Guidelines.

Key Definitions

Definitions

Medical Decision Making (MDM)Complexity of establishing diagnoses, assessing condition status, and selecting management options measured by number/complexity of problems, amount/complexity of data reviewed and analyzed, and risk of complications/morbidity/mortality.

Time-based E/M codingSelecting an E/M level based solely on time spent when the provider performs qualifying activities and documentation includes exact time and a descriptive narrative of activities performed during that time.

Recent Changes & Review Dates

07/01/2026Updated Definitions (administrative/clarifying)Latest

Updated Definitions section for clarity effective 07/01/2026 following the 04/01/2026 review; change identified as administrative/clarifying with no substantive clinical coverage change.

04/01/2026Review approved

Policy review approved on 04/01/2026 (linked to the Definitions update effective 07/01/2026).

Policy Summary

PayerAnthem

PolicyDocumentation and Reporting Guidelines for Evaluation and Management (E/M) Services - Professional

Policy CodePolicy C-09007

Change TypeDefinitions clarified

Effective Date07/01/2026

Next Review Date

SourceLink

On This Page

OpenPayer

Documentation and Reporting Guidelines for Evaluation and Management (E/M) Services - Professional

Policy Summary & Scope

Documentation & E/M Selection Criteria

E/M Coding Framework

Required Documentation & Billing Actions

Context & References

Key Definitions

Recent Changes & Review Dates

Documentation and Reporting Guidelines for Evaluation and Management (E/M) Services - Professional

Policy Summary & Scope

Documentation & E/M Selection Criteria

E/M Coding Framework

Required Documentation & Billing Actions

Context & References

Key Definitions

Concurrent Policies to Review

Recent Changes & Review Dates