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Payer changing cpt codes

  1. #1
    Default Payer changing cpt codes
    Medical Coding Books
    We have a payer (Caremore) that is changing our CPT codes on their end and not processing what was billed. For example 99215 was down coded to 99213. 99204 was downcoded to 99203. When discussing this with their "supervisor" she stated that their company will downcode anything greater than a level 3. I informed her that they could deny my claim but they could not change it. She then stated that anything higher than a level 3 needs documentation to pay at a higher level. Now, if our contract actually stated that, I know our providers would never have signed with them. We were told that NONE of their contracts contain any verbige to warn providers that this would be the case.

    For years I have been under the impression that a payer cannot change your submitted code without the knowledge or consent of the submitter. Unfortunatly I cannot locate anything that actually states this. There are fairly recent class action lawsuits where this issue has been part of the lawsuit but this has not deterred Caremore. Anyone out there have any words of wisdom?


  2. #2
    Greeley, Colorado
    I would like some information on that as well. Aetna has been changing our codes too.
    Lisa Bledsoe, CPC, CPMA

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