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Thread: Humana downcoding a new office visit

  1. #1

    Default Humana downcoding a new office visit

    AAPC: Back to School
    I have a situation where Humana/Tricare is downcoding a new patient office visit from a 99204 to a 99201. They are telling me that the reason is the patient filled out their own patient history form, and it was not filled out by the office. Does that make sense to anyone? They are telling me there is nothing I can do about it, that their say is final. It seems like I have read that the patient can fill out their own patient history form as well as their own review of systems. Any advise? I have never had this happen before and the really odd part is that the patient is a coder herself for the airforce and is the one who requested that Humana review the record, I think the patient just does not want to pay what she owes.

  2. #2
    Join Date
    Apr 2007


    Wow! Now that is interesting! Did the physician sign off on the form? Regardless if he did or not, I have never heard of such a thing. And besides that, are you able to get enough from the documentation without the form to at least get a 99202??

  3. #3


    The patient can fill out their own health and history form, it does have to be reviewed, signed and dated by the physician. If the physician did not review, sign and date the health history form this may be why they are not counting it. I would challenge them and ask them to show you any documentation that states that the patient can not fill out their form.

  4. #4
    Join Date
    Apr 2007


    The patient can fill out their own history form and you can use the CC, ROS, and PFSH. That is all you can use for history though.

    The provider still has to get the HPI on their own, just reviewing and signing what the patient wrote is not sufficient.

    Regardless if the patient wants to pay or not, obviously the documentation was massively overcoded if they reviewed it and dropped it to a 1.

    If she is a coder she probably knows the level of service provided was not what was billed. I am always mentally auditing my kids and my personal visits to make sure they are being billed correctly based on what was done. Now, I have no idea what was documented that could be a whole different story. If I find out they billed out a higher level of service than what I recieved and they made up documentation to support that I would be beyond livid and turn that provider in for falsification of medical records and anything else I could.

    I didn't mean to hop on a soap box but this issue really bothers me.

    Laura, CPC, CPMA, CEMC

  5. #5
    Join Date
    Apr 2007
    Columbia, MO


    He not only has to state it was reviewed but he must also note any postive responses as well as any pertinent negatives.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Join Date
    Apr 2007
    Louisville, KY


    Ah, nice trick, huh?

    Depending on your responses to the previous posters' suggestions, perhaps go through the route of filing a complaint. Does the payer have the authority to change codes on the claim form, especially since your practice/physician is ultimately responsible for the accuracy of that material? The downcoding is by the payer's estimate, but it must defend that stance through appeal. Be sure you utilize 1997 and/or 1995 guidelines to support your claim. There is likely something the contract that relates to Tricare's use of both sets.

    Finally, if the payer is altering your claim form contents (which is occurring through any downcoding), establish that is permitted in your contract. If the provider is solely responsible for the submitted claim, Tricare may be in violation of a number of regulations, contract provisions or laws. And, if the provider is "re-coding" the claim, that is likely a violation of conflict of interest clauses in your contract--though you'd need to have attorneys make that call.

    Finally, ask for a higher level determination by Erica Russel, the supervisor of that division.

    This might sound like a stretch, but I'd bet this practice is not permitted.
    Last edited by kevbshields; 02-17-2012 at 06:49 PM.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

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