Wiki Downgrading E&M services

[wellrusted51]

I have had Aetna Medicare downgrade 99214 to 99213 on 2 claims. We are an out of network provider. Has anyone had much luck appealing these downgraded claims?

 

[catherinetinkey@entmedicalservices.org]

We appeal all downgraded E/Ms if the documentation justifies the code. Is the Aetna plan a commercial plan or a Medicare plan? Do you have your out-of-network patients sign a waiver?

 

[wellrusted51]

We appeal all downgraded E/Ms if the documentation justifies the code. Is the Aetna plan a commercial plan or a Medicare plan? Do you have your out-of-network patients sign a waiver?

It is a Medicare plan. We do have them sign a waiver.

 

[csperoni]

I agree. Appeal anything underpaid when supported. If no one appeals properly billed services, the payor has little motivation to pay properly the first time.
Make your appeal concise & clear. State the level of problem, data and risk to determine overall level, or if billed on time highlight that statement. Like:
99214 is supported in the attached medical record. The problem supports moderate for 2 chronic problems (HTN & hyperlipidemia). Data for this visit was low for ordering 2 labs. Risk was moderate for continuing prescription of labetolol 100mg. This supports an overall moderate medical decision making, as correctly initially billed with 99214.

 

[rachaelwilleford]

Aetna has a downgrading policy that they base the level of service on what's provided on the claim - if there's something in documentation that substantiates the level of service, appeal. What CSperoni said above.

FYI - Aetna is not the only payer with a downgrading policy for Level 4 and 5 visits.

 

[Twhite]

Are there any webinars or information available to appeal these denials? It is my understanding that UHC has stated that all 99214 will automatically be denied. I'm looking for information for our insurance dept to appeal. Thanks in advance.

 

[rachaelwilleford]

Are there any webinars or information available to appeal these denials? It is my understanding that UHC has stated that all 99214 will automatically be denied. I'm looking for information for our insurance dept to appeal. Thanks in advance.

https://www.ama-assn.org/system/files/payer-em-downcoding-resource.pdf