Neurology & Pain Management Coding Alert

Question: One of our payers routinely downcodes our E/M services. What can I do about this problem?


Alabama Subscriber
Answer: First, check your contract with the managed-care organization to make sure that it permits the MCO to do this. If the contract doesn't discuss the issue, write to the payer and request the basis for the downcoding. Also, ask for a copy of its E/M documentation requirements, and then see which guidelines--1995 or 1997--they follow.

Check the neurologist's documentation against the appropriate guidelines, and if his notes meet or exceed the requirements for the code he billed, follow the payer's procedure for requesting an appeal or review.

Careful with level four: Neurology practices commonly complain when insurers downcode a level-four visit to a level-three visit, but physicians sometimes don't understand the difference between these two levels.

To qualify for a level-four E/M visit, you must document more than just a patient with multiple diagnoses. The physician must perform and document the qualifying criteria before you can code a level-four E/M.

Downcoding has become so widespread that several medical societies have secured settlements in class-action lawsuits against major HMOs, including Humana, Aetna, Cigna, Prudential and HealthNet.

If you encounter routine downcoding, don't hesitate to report it to your county and state medical societies.