Wiki E&M paid at lower level

cm@rlin

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We have been receiving Remittance Advice from a payer where several of the claims have a Remark/Explanation Code stating the E&M Paid at a Lower Level. Upon review, some of the E&M's submitted as a new patient level were downcoded to an established E&M level as well. Can a payer downcode or pay an E&M level at a lower level without requesting medical records before hand?

Any help in this area would be appreciated.

Cheryl
 
It may depend on your provider contract, but from my experience, some do downcode without requesting records. I ALWAYS appeal those.
 
If the claim was submitted in error as a new patient code when the patient was established, then it isn't down coding. In my experience, the payers that do this will pay the rate of the established code that is closest in value to the new patient code that was submitted, and this will usually be spelled out in the payer's published reimbursement policies. In such case, they are doing your practice a favor as some payers would simply deny the claim and force you to submit a corrected claim. Of course, if your records still show that this is not the correct payment based on what is documented, you can always recode and submit a corrected claim if necessary.
 
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