Insurance plans are down coding level 4 and 5 office visits with little to no guidance. Can someone please offer guidance (definition) on Prescription drug management which is under the risk portion of Coding based on medical decision making?
I would add that some insurances may downcode for a variety of reasons, even WITHOUT medical record review. In fact, Cigna just announced a new policy starting 10/01/2025 stating this exact scenario.
I read the policy a dozen times. No where does it state they may downcode after review of record, simply the "criteria on the
claim does not support" without explaining the criteria. Maybe by
diagnosis code??? My impression is that Cigna will be downcoding based on whatever criteria they determine, and then you can appeal for the correct payment, knowing full well that many claims will not be appealed for a variety of reasons (insufficient staff, past timely, didn't realize, etc.) other than they were originally overcoded.
"Cigna may adjust the E/M CPT ® code 99204- 99205, 99214-99215, 99244-99245 to a single level lower when the encounter criteria on the claim does not support the higher-level E/M CPT ® code reported. For example, a claim may be adjusted as follows: 99215 to 99214, or 99214 to 99213.
When a code level has been adjusted and, subsequently, medical records are submitted that substantiate the complexity and Medical Decision Making (MDM) or time associated with the reported E/M CPT ® code level, the code will be reimbursed at the level initially submitted."
In my opinion,
every incorrect denial should be appealed, even if it takes $20 to recoup $15. Make it cost the payor to spend time reviewing incorrectly downcoded claims. As long as your level 4 and level 5 visits are correctly coded, create form letters where you can fill in the blanks to quickly get the appeals back to the payor.
