CurrentBlue Cross Blue Shield - MainePolicy C-09007

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

Defines documentation and reporting requirements for reimbursement of E/M services for providers billing the health plan, aligning with CMS and AMA CPT guidance and affecting professional providers submitting claims to Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

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

Policy CodePolicy C-09007

Change TypeNo material change

Effective DateSep 11, 2025

Next Review DateN/A

Key ActionProviders must bill E/M services with documentation that supports the selected level (including exact time and description of activities when time is used) to avoid claim denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2021MDM framework used to select E/M level

AllowedTime-based reporting allowed

NonePolicy contains no exemptions

EncoderPro/CMSReferences included

HistoryPolicy history entries

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Documentation Criteria

Reimbursement is allowed when documentation and billing meet the policy requirements below; the plan follows CMS guidance and uses the 2021 AMA CPT Medical Decision Making (MDM) table to determine E/M level.

Documentation, coding, and billing must meet the policy requirements; claims may be recouped, rejected, or denied if coding/billing guidelines are not followed.

Applicable setting: Office/other outpatient and ‘other’ E/M services (inpatient, observation, ED, nursing facility, domiciliary/rest home, home visits, cognitive impairment assessment). The plan follows CMS guidelines for documentation and determination of service level except where this policy differs.

ALL of the following

An assessment, clinical impression, and/or diagnosis must be documented (may be explicit or implied in management decisions).
Presenting problems must be addressed in history, physical exam, and MDM components.
ONE of: For presenting problems with an established diagnosis, the record should reflect whether the problem is improved/well controlled/resolving/resolved OR inadequately controlled/worsening/not changing as expected.
For presenting problems without an established diagnosis, initiation of or change in treatment must be documented.
If diagnostic services are ordered/planned/scheduled/performed at the time of the E/M encounter, the type of service must be documented.
If referrals/consultations/advice are made or requested, documentation must indicate to whom or where the referral or consultation is made or from whom advice is requested.
Review of lab, radiology, and/or diagnostic tests must be documented (a simple notation or provider initial/date on report is acceptable).
Relevant findings from review of old records or additional history from family/caregiver/other sources must be documented; if no additional relevant information exists, that should be stated (a bare notation like 'old records reviewed' without elaboration is insufficient).

ALL of the following

The health plan uses the 2021 AMA CPT Level of MDM Table to quantify complexity of problems addressed, amount/complexity of data reviewed/analyzed, and risk of complications/morbidity and mortality to determine the appropriate E/M level.

ALL of the following

If time is used to select an E/M level, the exact time of service must be documented (not an approximate range) and the activities performed during that time must be described.
If the time documentation requirement is not met, the E/M level will be determined by MDM.

ALL of the following

This policy is subject to provider, state, or federal contracts and mandates; documentation Standards for Episodes of Care policy applies.
No exemptions to this policy.

E/M Level Selection and Time Reporting

E/M Level SelectionCPT

2021 AMA CPT E/M MDM Table

Used to quantify problem complexity, data reviewed, and risk to select E/M level

Time documentation requirement

Exact time of serviceProvide an exact time of service (not an approximate range) supported in the medical record.

Activities performed during timeDocument a description of the individual activities performed during the stated time (not just a list of allowed elements).

Medical appropriatenessDocumentation must support the medical appropriateness of the visit when time is used to select the E/M level.

Fallback to MDMIf time documentation requirements are not met, the claim will be evaluated using Medical Decision Making (MDM) criteria to establish the level of service.

Billing, Authorization, and Provider Responsibilities

Billing Rule

Billing, Authorization, and Denial Risk for E/M Services

Providers must bill E/M services using industry-standard, compliant codes (CPT, HCPCS, revenue codes) and ensure all billed services are fully supported in the medical record or office notes. Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence. Failure to follow coding/billing guidelines or current reimbursement policies may result in recovery/recoupment of claim payment, or claim rejection or denial.

Use proper billing and submission guidelines and compliant codes on all claim submissions (CPT, HCPCS, revenue codes).
Document and support billed services in the medical record/office notes.
Ensure services meet authorization and medical necessity guidelines for the procedure, diagnosis, and member's state.
Be aware that noncompliance may lead to payment recovery/recoupment, or claim rejection/denial.

Key Definitions

Medical Decision Making (MDM)

Definition of MDMMedical Decision Making (MDM) is the complexity of establishing diagnoses, assessing condition status, and selecting management options; determined by number/complexity of problems, amount/complexity of data reviewed and analyzed, and risk of complications/morbidity/mortality.

Components used in MDMMDM requires assessment of: (1) number and complexity of problems addressed, (2) amount and/or complexity of data to be reviewed and analyzed, and (3) risk of complications and/or morbidity or mortality of patient management.

Role in level selectionThe health plan uses the 2021 AMA CPT Level of MDM Table to quantify problem complexity, data reviewed, and risk when selecting the E/M level.

Time-based E/M reporting

When time may be usedAs described by CMS, time alone may be used to select a code level for certain E/M services when documentation meets the policy requirements.