Format: Live Webinar | Presenter: Susan Rohde, RHIT, CCS-P, CPC | Event Date: Thursday, February 27, 2025
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT | Duration: 60 minutes | Location: Online Webinar
Payer downcoding occurs when the payer assigns a lower-level code to a medical service or procedure than what was submitted to the payer for the patient without review of the medical record. This results in lower reimbursements that can significantly impact a physician’s bottom line. Providers can take certain steps to avoid payer downcoding, such as using the correct code set. Providers and payers are required to use standard code sets designated by the U.S. Department of Health and Human Services (HHS) such as CPT’s evidence-based codes, which accurately encompass the full range of health care services.
The American Medical Association (AMA) created new Evaluation and Management (E/M) guidelines, to reduce the documentation burdens placed on providers. Following the changes, several payors began implementing algorithms, within their systems, that inappropriately down-coded claims, causing payment reductions. To the frustration of providers, payers are increasingly implementing E/M downcoding programs that inappropriately reduce payment for claims billed. Often, these reduced payments, go un-noticed, as staff is looking for full denials, and not claim payment reductions.
Most often, a claim is down-coded because the payer disputes the use of a higher-level E/M code or states that the diagnosis code submitted on the claim does not warrant a high-level service code. An increasing number of payers are downcoding claims automatically using software algorithms, without first requesting and reviewing clinical records. Inappropriate downcoding by payers can significantly reduce revenue for physician practices, especially when it becomes routine or when a physician becomes subject to global prepayment review. Facilities will need to implement guidance to staff on how to review remittance advices to identify downcoding, provide proper education to staff on documentation guidelines, and educate staff on how to obtain successful appeals when downcoding occurs.
Susan Rohde, RHIT, CCS-P, CPC, has more than 28 years of experience in health care industry with an emphasis in coding, health information management, medical necessity and documentation. Susan is currently serving on the education committee for NSCHBC. Her other memberships include AHIMA, NDHIMA, AAPC, NSCHBC, HFMA and MGMA. She specializes in reviewing documentation for accurate reimbursement within Evaluation and Management (E/M) and all surgical specialties, including Interventional Radiology, Anesthesia, Neurosurgical, and Orthopedics, for both ICD-10-CM and CPT codes. Susan helps navigate the ever-changing coding and documentation world and can help your organization in maximizing its coding potential via proper documentation, provider and coding staff education, and understanding of guidelines and regulations.
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