Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has announced a new Office and Other Outpatient Evaluation and Management (E&M) Leveling Program and updates to its E&M reimbursement policy. Beginning August 15, 2026, select providers may be subject to additional review of office and outpatient E&M claims to help ensure coding aligns with national industry standards.
For physicians, advanced practice providers, practice managers, coding professionals, and billing teams, now is a good time to review E&M documentation and coding practices to understand how this change may affect claims processing and reimbursement.
What Is the E&M Leveling Program?
The new E&M Leveling Program is designed to support accurate and consistent coding and reimbursement. Blue Cross NC will identify providers whose E&M coding patterns are consistently higher than those of their peers and evaluate whether submitted E&M services are supported by the services and conditions documented in the claim.
The review process uses analytics supported by human and clinical review. If Blue Cross NC determines that the billed E&M level is higher than what is supported by the documentation and services submitted, the claim may be denied or reimbursed at a different E&M level. Providers may use the standard claims dispute process to request a review of any determination.
Who Will Be Affected?
The updated reimbursement policy does not automatically apply to all providers.
Only providers identified for participation in the E&M Leveling Program will be subject to the additional review process. Blue Cross NC has indicated that providers selected for the program will receive advance notification. If your practice does not receive a notification letter, no further action is required regarding program participation.
The policy applies to:
- Blue Cross NC Commercial plans
- Blue Cross NC Medicare Advantage plans
The policy does not apply to:
- Federal Employee Program (FEP)
- Inter-Plan Program (IPP) Host
- Inter-Plan Program (IPP) Home
What Should Practices Do Now?
Even if your organization has not received a notification letter, this announcement serves as a reminder of the importance of accurate E&M coding and thorough clinical documentation.
Practices may want to review:
- Current E&M coding processes
- Documentation supporting medical decision-making and time-based coding
- Internal coding education and auditing activities
- Opportunities for provider and staff training related to E&M guidelines
Practices that receive notification of program participation may also wish to work closely with coding, compliance, and revenue cycle teams to monitor adjudication outcomes and address reimbursement questions.
Why This Matters
E&M services account for a substantial portion of outpatient reimbursement. Changes in payer review processes can affect reimbursement, claim adjudication, and administrative workload. Maintaining strong documentation practices and ensuring coding accuracy can help practices prepare for reviews and support appropriate reimbursement.
As payers continue to focus on coding accuracy and documentation standards, ongoing provider and staff education remains an important component of practice operations.
Learn More
Blue Cross NC has published additional information about the program and related reimbursement policies:
- New E&M Leveling Program and Updated E&M Reimbursement Policy
- Blue Cross NC Provider Policies, Guidelines, and Codes
- Provider Policy Notifications
NC AHEC Practice Support Takeaway
While the E&M Leveling Program will only apply to selected providers, all practices can benefit from regularly reviewing coding and documentation processes. Ensuring that E&M services are fully supported by clinical documentation can help reduce claim denials, support appropriate reimbursement, and prepare practices for evolving payer review programs.
Accurate coding, complete documentation, and ongoing education can help practices navigate payer policy changes while maintaining efficient revenue cycle operations.
