February 16, 2022

Automatic downcoding of E&M services

We see an increased volume of automatic down coding by several large commercial carriers.

We deduced that down coding is done using three factors - comparative coding pattern of the provider vis-a-vis peers, diagnoses addressed, and prior visit history of the patient.

Detecting and appealing these down-code decisions takes valuable time for most practices with in-house billing resources. In several cases, it may not be worth the difference in payment. Detecting these denials is also a challenge since the automatic posting of Electronic Remittance Advice (ERA) can fail to highlight these down-coded claims.

In Glenwood, we appeal these decisions individually. To substantiate the billed E&M level, we have to produce documentation that supports the billed level. If a diagnosis addressed during the visit was missed in the original claim, it is easy to add the diagnosis to the claim and appeal based on added Medical Decision Making (MDM) complexity. If the diagnoses were correctly listed on the original claim, it is best to substantiate using the time-spent rules.

Time-spent can be a sole deciding factor for E&M level since 2021. Time spent now includes pre-visit record review, face time, post-visit documentation, post-visit phone and documentation time, incoming results review, and documentation time. In GlaceEMR, the total time spent can be noted in the Plan section.

As these types of underpayments increase and significantly impact your practice bottom-line, it is essential to detect these denials and address them appropriately with appeals and documentation.

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