Downcoding Lab Services

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We are an independent lab. Humana and Cigna now have policies in place that they will not reimburse any higher than a G0480 tox for Humana and a G0481 tox for Cigna. What Cigna does is downcode when they reimburse and Humana pays the higher tests than recoups a couple months later and we have to bill a new claim with the G0480 What we would like to do is just bill at those levels but still test and report what the provider ordered. This would greatly simplify working denials and payment posting for us.
My concern is that we get into a compliance issue; since the payers have specific policies in place , would that cover us for downcoding? Thank sin advance!
 

JenniferB7

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Local Chapter Officer
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Victoria, TX
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According to Cigna and Humana policies (attached), codes G0482 and G0483 (for Cigna) and G0481-G0483 (for Humana) are non-covered/non-medically necessary services. This means the patient is responsible for the service.

It would be considered a false claim (violation of the False Claims Act) to intentionally downcode the service in order to obtain insurance reimbursement. You should always bill correctly according to the service that was provided. If code G0843 accurately describes the service provided, then that is what you must code. If it is not covered by Cigna/Humana, then you must obtain payment from the patient.

Here is an article you may find helpful: https://www.aapc.com/blog/26957-undercoding-is-no-better-than-overcoding/

Hope that helps!
 

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