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 Evaluation and Management Coding and Accuracy.
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 E11.621 diabetes code (diabetes with a foot ulcer), it is impossible to determine based on the claim how many DFUs are present. (Remember that E11.621 is a diabetes code, not an ulcer code.) Even when a diabetic foot ulcer (DFU) is coded correctly using both the E11 code and an L97 chronic ulcer code, ulcers that are in the same anatomical location will be collapsed into one code, again reducing apparent patient complexity. The right documentation platform with automatic diagnosis coding could help. This is yet another example of why the lack of a specific code for “diabetic foot ulcers” (or arterial ulcers) hurts wound care practitioners.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
