Wiki 99204 down coded to 99203

cfwh671

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Medicaid keeps down coding all my 99204s to 99203s regardless of the type of visit. I requested a scoresheet to justify the down code, but they only tell me the Medical Decision Making is low complexity. They refuse to tell me why they decided it's low complexity. I don't think they bothered to read through the encounter.

Is there an E/M scoresheet used by CMS to audit these visits? Please point me in the right direction on what I can use to appeal these down codes.
 
Here is an audit form from my local MAC:
Evaluation and Management Documentation Tool
Each MAC usually has their own particular form they use, but they're all based off of the 1995/1997 E/M Guidelines that CMS uses.
Good luck appealing, but remember that since medical necessity is the overarching criterion for payment and not just the volume of documentation, if the nature of the presenting problem doesn't warrant that high a level of care, they'll down code it. Best of luck though!
 
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