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BCBS downcoding E/M services

R

Ree923

Contributor
Messages
18
Location
Bolingbrook, IL
I have just learned that BCBSIL is starting to downcode based on MDM and we will need to submit formal appeals for each claim denied. I also see that IL just signed a law stating that this is not allowed? I am unclear of how to move forward. Our clearinghouse does not allow records to be sent with claims, but the volume of appeals that will be needed makes me concerned. Does anyone know what is happening with the downcoding issues?
 
Hi, I did a bit of searching and Illinois' Transparency in Downcoding Act doesn't go into effect until Jan 1, 2028. (The original version of the bill would have been effective when it was signed into law). This happened recently so BCBSIL might withdraw the policy.

www.isms.org/newsroom-categories/isms-news/may-28-2026-transparency-in-downcoding-act-unanimo
 
This is happening a lot. Your physician's medical specialty organizations probably have some advocacy resources and also a state medical society or medical group management organization can help advocate for fair payment consistent with CPT coding guidelines that require MDM or total time and not specific diagnosis codes (used by payer algorithms to downcode claims). It may also be possible to file a HIPAA complaint (https://asett.cms.gov/complaints) when the payer is not paying based on submitted codes.
One thing that your practice can do is to be sure that the diagnosis codes on each claim reflect the conditions addressed (eg, moderate intermittent stable asthma or moderate persistent asthma with exacerbation).

Wishing everyone good luck with this.
Cindy
 
FYI multiple states are passing legislation, however state laws typically only apply to fully funded plans. Employer funded plans fall under ERISA, which is a federal law. Also, these payers is notifying providers of changing policies, including downcoding policies in their newsletters and provider notifications. Someone in the office really needs to be monitoring these communications and disseminating information to the office/health system.
 
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