Wiki BCBSGA/Anthem 99214-99215 Denied/Down coded

[lisa30052@gmail.com]

Is anyone else having issues with BCBS of GA down coding 99214 to 99213 or denying 99214 as an invalid CPT code for services billed? BCBS requested records upfront for all clinic claims and then down coded all the 99214 to 99213. And since they finished this "audit', they are kicking out every claim that has been billed with 99214 or 99215. Has anyone else had this issue recently or in the past? We are going to appeal but I wanted to get some suggestions as to how to appeal so many claims (Over 200). Any suggestions would be appreciated.

 

[mnuhfer04]

Is anyone else having issues with BCBS of GA down coding 99214 to 99213 or denying 99214 as an invalid CPT code for services billed? BCBS requested records upfront for all clinic claims and then down coded all the 99214 to 99213. And since they finished this "audit', they are kicking out every claim that has been billed with 99214 or 99215. Has anyone else had this issue recently or in the past? We are going to appeal but I wanted to get some suggestions as to how to appeal so many claims (Over 200). Any suggestions would be appreciated.

I have as well, but with Fidelis (I am in NY). When this happens, I fill out an appeal form, print out the AMA 2021 E/M Guidelines and write a short letter explaining why this date of service meets the criteria for a 99214. I send that, along with the claim form and medical record to the insurance company. I have had a lot of success getting the correct amount paid, it's tedious work, but so far so good on our end. I created a templet for the letter that I write so that I just have to add in the patients name and how the criteria is being met.