Wiki Downcoding to receive reimbursement when higher level code is not payable

[ashley.gore]

Hi there,

I'm trying to find documentation from CMS or the False Claims Act that specifically indicates that it is fraud or false reporting of claims to bill out a lower level code for reimbursement when the higher level code that actually occurred is not payable due to the fact that an authorization was not obtained. Since the lower level does not require an auth and auth wasn't obtained for the actual level of care that was provided, I'm being asked to downcode to the level that does not require an auth. This is not just for one claim here or there, this is between 50-80% of the services provided where auths weren't obtained for the correct level of care so the provider wants them downcoded to the level that doesn't require an auth.

Does anyone have documentation that they could send me from CMS or from the False Claims Act that specifically mentions downcoding abuse.

Thank you for your help!

 

[CodingKing]

Not sure if this helps but discusses downcoding and how it can meet the definition of a false claim

https://www.aapc.com/blog/26957-undercoding-is-no-better-than-overcoding/

CMS definition:

In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. In other words, fraud includes the obtaining of something of value through misrepresentation or concealment of material facts.

It would be hard to argue downcoding isn't a misrepresentation of material facts.

 

[mitchellde]

Hi there,

I'm trying to find documentation from CMS or the False Claims Act that specifically indicates that it is fraud or false reporting of claims to bill out a lower level code for reimbursement when the higher level code that actually occurred is not payable due to the fact that an authorization was not obtained. Since the lower level does not require an auth and auth wasn't obtained for the actual level of care that was provided, I'm being asked to downcode to the level that does not require an auth. This is not just for one claim here or there, this is between 50-80% of the services provided where auths weren't obtained for the correct level of care so the provider wants them downcoded to the level that doesn't require an auth.

Does anyone have documentation that they could send me from CMS or from the False Claims Act that specifically mentions downcoding abuse.

Thank you for your help![/QU
It is a misrepresentation to submit a code for something other than what is documented which is the very essence of the false claims act. when you state authorization was obtained for a lesser service then I assume you are speaking of a surgical procedure as visit levels do not require prior authorization. If you obtained an authorization for a service that was intended however something more extensive needed to be performed due to conditions not forseen by the physician, then most payers do allow a period of time, usually 1 working day, to post authorize the procedure that was needed. if this was not done timely, you will need to submit the claim correctly and you can try to appeal if it does get denied.
you are speaking of a very high volume of claims that are documented for a higher level than what you can be reimbursed for due to no authorization. This is actually a very serious problem for that many claims. You absolutely cannot just downcode these in order to receive reimbursement. Claims must be coded to what the documentation supports. If this means there will be no reimbursement then there is the problem. The regulation does not need to specifically include the language "downcoding" for you to know this is being addressed in the language of the act. They clearly state that a false claim is misrepresenting the information on the claim to obtain reimbursement. whether this means upcoding or downcoding, it is all the same.