Starting July 1, 2026, Blue Cross and Blue Shield of Texas (BCBSTX) will “enhance” its claims editing and review process for office, inpatient, and outpatient evaluation and management (E/M) services for patients in commercial BCBSTX plans.
For dates of service on or after July 1, BCBSTX’s new claims editing and review process will assess whether services billed support the E/M code level as reported on the claim. If the insurer determines that the services billed do not support the reported E/M code level, it will unilaterally lower its payment for those services to that of a lower-level E/M code – a process known as downcoding. Accurate E/M level codes directly impact reimbursements.
BCBSTX says the new claims editing and review process will follow the American Medical Association’s guidelines for level of service and medical decision-making. If a physician does not agree with the level of service for which they were paid, BCBSTX says they can submit medical records to support their claim. Here is a link to the policy on coding. In October 2025, a Cigna policy reduced physicians’ payment for high-level evaluation and management services, including complex care based on the encounter criteria in a submitted claim.
It is not clear how the payers’ computerized claims editing process will determine whether the E/M code is correct without a review of the chart. It is true that elements such as the number and type of diagnoses and whether studies and labs were ordered provide some indication of patient complexity and physician work. However, patient complexity and cognitive effort are too nuanced to be accurately determined by claim data alone. This is a particular problem for patients with chronic wounds. More than 85% of patients with chronic wounds have more than one wound. If clinicians incorrectly code diabetic foot ulcers using only the E11 diabetes code (diabetes with a foot ulcer), it is impossible to determine based on the claim how many DFUs are present unless they use multiple codes. Even when the chronic ulcer codes are used correctly, ulcers that are in the same anatomical location will be collapsed into one code, again reducing apparent patient complexity. That is why Intellicure’s automatic diagnosis coding guides clinicians to properly use two codes to diagnose diabetic foot ulcers and arterial ulcers.
Since 2000, the Intellicure electronic health record (EHR) has been able to internally audit the clinicians’ documentation and calculate the correct E/M code based on the Medicare coding requirements – incorporating the changes made in 2022 to the E/M calculations. Intellicure’s ability to internally calculate the correct E/M charge provides an additional level of confidence when billing private payers. While the payer’s automated claims editing process may still improperly downcode services (since claims alone do not provide sufficient data to correctly assess E/M level of service) Intellicure users can have the confidence that, if audited, their billed E/M will stand up to scrutiny if they relied on Intellicure’s internal E/M calculation when submitting charges.
