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How You Can Recognize Private Payer E/M Downcoding
Have you ever noticed lower reimbursement than what you expected from a private payer? In recent years, several private payers have announced downcoding programs for evaluation and management (E/M) services, the rationale being to reduce potentially inappropriate use of upper-level E/M services visits. Some payers use an algorithm-based program that assigns the E/M level based on diagnosis codes. While payers do provide updates to providers when they are implementing programs associated with downcoding (normally in the payer newsletters), the AAN wants to provide members with tips on how to identify downcoding:
Review your provider remittance or explanation of benefits. The payer may not change the actual coding on the claim, but the payment will be that of the level their program determined to be appropriate.
Familiarize yourself with advice codes. The following codes signal downcoding:
CO150: Payer deems the information submitted does not support this level of service
M85: Subjected to review of physician evaluation and management services
N610 Alert: Payment based on appropriate level of care
CARC 186: Level of care change adjustment
Payments are less than anticipated rates based on allowable.
If you notice downcoding, it is recommended to review the claim submitted to confirm if a lower level was appropriate. If you find the records don’t reflect the downcoding, you have the option to appeal the claim. When appealing, it is important to provide excerpts from the CPT E/M documentation guidelines or the payer’s medical policy to support your appeal.
Other tips to consider if your claim is downcoded:
The use of independent certified coders to evaluate the claims and medical records in questions may be beneficial and provide substance to any appeal.
Some of the information that supports the code level might not be in the progress note itself but on procedure sheets. These forms are sometimes overlooked when submitting records to a payer.
If you have any questions or would like more information, contact practice @ aan.com
