Practice Management Alert

Question: A payer I work with consistently downcodes our claims and never gives us warning or asks for documentation to verify the claim. We do not have a lot of Molina patients, but of the ones we do have, every single claim gets downcoded from 99214 to 99213. We do not receive a notice in advance. We do not receive a request for medical records substantiating the charges. Molina just automatically assumes we chose the wrong CPT^® code.

Is this happening for anyone else? How do we prevent this from happening? Is this illegal for them to do this? We are upset they aren’t requesting documentation before doing this, and our provider really does spend the time and energy providing these services to his patients.

AAPC Forum Participant

Answer: This isn’t illegal; payers set contracts and there may be nuggets like this within those contracts when your provider signs.

Molina Healthcare released a statement in March 2020 explaining its perspective on certain evaluation and management (E/M) services, noting that the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) both acknowledge that E/M services are the most likely to be incorrectly coded and the cause for incorrect payment.

The OIG says payers should develop programs to “review” E/M services billed by “high-coding practitioners,” Molina Health says. Molina lists the following remittance messages as possible replies to E/M claims that they process:

• “‘Line (X) Service Code ‘99204, 99205, 99215, 99214’ visit level lowered to ‘99203, 99204. 99213, 99214.’”
• “This claim line was processed using a code that more accurately represents the treatment received.”
• “The information submitted on the claim does not support the code originally billed. The provider has been reimbursed using the level (insert level) evaluation and management code which more appropriately supports the information submitted on the claim.”
• “Payer deems the information submitted does not support this level of service.”

While noting that providers can file a dispute, Molina explains that medical necessity should be the primary means of evaluating the appropriateness of a code.

“Medical Necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level or service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed,” Molina Health says.