Eli's Rehab Report

Question: One of our carriers requested documentation when we billed 99215 to evaluate a patient's sprained wrist (842.0x). It later sent us reimbursement for 99214. The physiatrist thinks we should accept the lower payment, but I think the physician's documentation justified the higher code because the patient also has lupus (710.0), which made the evaluation more complex. Should we appeal this claim or just accept their response with the lower reimbursement?

Delaware Subscriber

Answer: You should definitely respond to the insurer. You can never be too concerned about regulatory exposure, and if you don't respond, it might look as if you're admitting that you upcoded your E/M claim. Review your documentation to ensure that it reflects the components required for a 99215 (Office or other outpatient visit ...). Chances are, your carrier randomly selected level-five E/M claims for review, and your documentation did not support its use.

If you believe that your documentation supports the claim, send the insurer a letter with another copy of your documentation, circling the "bullets" that justify billing a 99215.

Based on this letter, the insurer may revise its original position and pay you the difference between the two codes (about $40), or it may respond with a more detailed explanation of why it downcoded the claim. The important part is that you stated your case and demonstrated why you coded the service the way you did.