Down coding

AR2728

Expert
Messages
313
Location
Perryville, MO
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0
Everything I have seen and heard over the years states it is just as bad as upcoding. However, we do have an EMR and there are times when our physician should downcode based upon medical decision making. It's very easy to push an established visit to a level 4 or 5 by providing a detailed/comprehensive history and physical, and some physicians prefer to document to that level at every visit. However, many of our payers require medical decision be one of the two components used to determine the E&M level.
That being said, we do have cases where our system would code out a level 4, but the medical decision making falls into the low category and the visit is ultimately billed as a 3.
 

mitchellde

True Blue
Messages
13,537
Location
Columbia, MO
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2
es downcoding is every bit as bad as overcoding. Both represent a false claim submission. AR2728, what you are doing I do not feel would be considered downcoding. When coding established patient encounters even though it is 2 out of 3 components, unless there is something significant to the history, we are told to weigh the decision more heavily toward the decision making. History all too often is simple pulled forward from a previous encounter, so to let it drive the encounter would be wrong, I am in agreement with your methods.
 

vpat28

Networker
Messages
35
Location
NORTH BRUNSWICK, NJ
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0
Down Coding

So does medicare fines providers for down coding? I am really looking something where it says that down coding is also fraud. Please help me to find something in writing!!!!
 
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