Wiki Downgrading E&M services

[wellrusted51]

I have had Aetna Medicare downgrade 99214 to 99213 on 2 claims. We are an out of network provider. Has anyone had much luck appealing these downgraded claims?

 

[catherinetinkey@entmedicalservices.org]

We appeal all downgraded E/Ms if the documentation justifies the code. Is the Aetna plan a commercial plan or a Medicare plan? Do you have your out-of-network patients sign a waiver?

 

[wellrusted51]

We appeal all downgraded E/Ms if the documentation justifies the code. Is the Aetna plan a commercial plan or a Medicare plan? Do you have your out-of-network patients sign a waiver?

It is a Medicare plan. We do have them sign a waiver.

 

[csperoni]

I agree. Appeal anything underpaid when supported. If no one appeals properly billed services, the payor has little motivation to pay properly the first time.
Make your appeal concise & clear. State the level of problem, data and risk to determine overall level, or if billed on time highlight that statement. Like:
99214 is supported in the attached medical record. The problem supports moderate for 2 chronic problems (HTN & hyperlipidemia). Data for this visit was low for ordering 2 labs. Risk was moderate for continuing prescription of labetolol 100mg. This supports an overall moderate medical decision making, as correctly initially billed with 99214.

 

[rachaelwilleford]

Aetna has a downgrading policy that they base the level of service on what's provided on the claim - if there's something in documentation that substantiates the level of service, appeal. What CSperoni said above.

FYI - Aetna is not the only payer with a downgrading policy for Level 4 and 5 visits.