Your insurer may not announce that they’re downcoding your E/M services, but it’s likely that one or two claims are being automatically readjusted to lower E/M levels every month. And for every downcoded claim, your practice is losing money.
Check out a few of the most commonly downcoded E/M services, along with tips on how your practice can avoid facing these downcodes.
- 99204
When you report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded), you’re telling the insurer that you performed high-level E/M services.
But some insurers balk at paying for these services, which cost significantly more than lower-level E/Ms. For instance, Cigna recently announced it would launch automatic downcodes for some E/M services reported with 99204-99205. This means that if you report 99204, you could receive a payment for 99203 instead. That’s a $55 difference.
To ensure your documentation supports 99204, your documentation should clearly state the time spent (at least 45 minutes) or should demonstrate a moderate level of medical decision making. You don’t need to demonstrate both to report 99204, but having both the MDM and the time spent clearly shown in your documentation can help you support an appeal if your claim is downcoded.
- 99215
Code 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded) is also among the E/M services targeted for automatic downcode in certain cases by Cigna.
To avoid getting your 99215s downcoded to 99214 (or even 99213), ensure that you have documented a high level of medical decision making for your E/M services. Alternately, you can ensure that you’ve documented at least 40 minutes of total time (including seeing the patient, reviewing their records, talking to other doctors about their care, and any other responsibilities that relate to the patient’s care).
- 99244
While not all insurers accept consultation codes, some do — and 99244 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded) is among the codes that Cigna has targeted for automatic downcodes in certain instances.
Payers will reimburse about $155 for 99244, while a downcode to 99243 will pay about $45 less. For that reason, ensure you have documented not only a moderate MDM or at least 40 minutes of time spent, but also the consultation requirements. These include a referral by another provider, as well as a review of the patient’s situation and a report back to the referrer.
| You don’t have to accept payer downcodes — fight back to hang on to the E/M pay you deserve! Let experts Jill Arena and Anne Hirsch, MD, walk you through how during their online training, Stop Downcoding: Get Paid More for Your High-Level E/M Claims. Sign up today! |