Wiki Payors automatically downcoding ER levels

[Sochrissy]

Has anyone experienced payors that are automatically downgrading ER levels? Specifically Levels 4 and 5 downgrading to 2 and 3.

Most have enough documentation to meet the criteria for level 4 or 5. Is that enough to appeal this decision or does the diagnosis code factor into the level as well?
I have heard that CMS states that the dx code can dictate the level...if this is accurate does anyone have a link or documentation on this from CMS?

Any help would be appreciated

Thank you!

Chrissy
CPC-A, CRCR

 

[meghanhannus]

Hello Sochrissy,

Some payors have their systems setup to automatically down code E/M visits including ER based on the diagnosis code (s) alone. If the documentation supports the ER level 4 (detailed history, detailed exam and moderate MDM) & ER level 5 (comprehensive history, comprehensive exam, high MDM) then I would recommend sending in an appeal along with the supporting documentation to be reimbursed appropriately. Sorry, but I do not have any links or information from CMS. I suppose by what they are saying they are looking more at the medical necessity of the visit for example a patient seen in ER for an ankle sprain with no chronic conditions probably would not be supportive of level 5 billing where as a patient in the ER for a myocardial infarction with other chronic conditions such as HTN or DMI would probably support level 5 billing based on diagnosis/medical necessity of the visit.


Hope this helps

M.Hannus, CPC, CPMA, CRC

 

[Sochrissy]

Thank you for your response! Exactly, the payors that have systems set up to automatically downgrade based on the dx code.

For example, a claim has enough information documented to meet all requirements for 99284 but the diagnosis code is Dermatits and rash. So I am trying to understand if it's correct for payors to use the diagnosis as the overall determination even if the documentation meets CPT requirements for 99284?

 

[meghanhannus]

Thank you for your response! Exactly, the payors that have systems set up to automatically downgrade based on the dx code.

For example, a claim has enough information documented to meet all requirements for 99284 but the diagnosis code is Dermatits and rash. So I am trying to understand if it's correct for payors to use the diagnosis as the overall determination even if the documentation meets CPT requirements for 99284?

I would assume it is a cost savings for the payor to down code and have the provider appeal rather than pay for higher level e/m services unnecessarily.