Practice Management Alert

Question: I have a payer who 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 (MCO) to make sure that it doesnt permit the MCO to do this. If the contract doesnt 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. Then, see what guidelines 1995 or 1997 they follow. Check the doctors documentation against the appropriate guidelines and, if his or her notes meet or exceed the requirements for the code billed, follow the payers procedure for requesting an appeal or review.
 
Insurers downcoding a level four to a level three is a common complaint, but physicians sometimes dont understand the difference between these two levels. To qualify for a level-four E/M visit, more is involved than having a patient with multiple diagnoses. The physician must perform and document the qualifying criteria. If not, a level-four E/M should not be billed.
 
Downcoding has become such a widespread problem that several state medical societies have filed a class-action lawsuit against six major HMOs. Report routine downcoding to your county and/or state medical society. You may find that this is a common problem in your area and that the medical society is working on it.