Wiki Question

[Chadito13]

Hello everyone, I have a question: is illegal for a payer to change the codes or not? . I billed an insurance for the code 99214. They changed the code 99214 for 99213 and paid the claim. Saying that medical records do not support code 99214. Is this legal or illegal?? Hope somebody can help me. Thanks.

 

[thomas7331]

This is common practice and not illegal. Insurance companies cannot 'change' your codes, but in a case like this they have not actually changed it - they have just changed the payment based on the rate for the code that they think should have been submitted. They still retain the record of the code that you originally submitted. If you disagree with their payment determination, they should have an appeal process that you can follow.

 

[Jlyak@live.com]

No not illegal. This is common, they will say they "downcoded" because med recs don't support. You can appeal