Reducing the Level of Service / E&M

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cling2me2

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Hello. I would appreciate hearing others thoughts on the following issue please. Is there one correct answer?

Scenario: CPT 99214 billed. Carrier requests records for a pre-payment review. OV notes are submitted. Carrier reviewed the records and denied the E&M as level of service not documented in the medical record. We think the 99214 is supported, carrier does not. Can we reduce the E&M to a lower level E&M and submit as a corrected claim?

I have had 2 different responses to this issue.
1. If you resubmit with a lower level of service, that is down-coding and incorrect.
2. If the provider chooses to lower the E&M code, that is his prerogative and there is nothing wrong with that. (Coding is somewhat subjective, so if the provider agrees that his level of service is lower than he originally billed, he can submit a correction with a lower level E&M.)

I look forward to any & all input on this issue.
Thank you!
 
My take is:
- If you disagree with the carrier, then appeal, appeal, appeal.
- If you agree that the original 99214 is incorrect, then yes, submit a corrected claim.
Remember that the coding must be based on the documentation. There are many times a clinician PROVIDES a 99214, but DOCUMENTS a 99213. If documentation supports 99214, then appeal specifying the level of problem, data and risk to support your 99214.
 
Hi Christine. Thank you for your response.
We have submitted appeals and they are being denied as original denial upheld. Carrier is UHC.
I appreciate your time and response.
 
I would just add that one reason to appeal when a practice thinks it has a case is to let the payer know that it disagrees with the payer's findings. If a practice simply accepts downcoding, the payer might downcode more claims. But again it is only an option when the documentation supports the service.
 
Fight it. Submit additional documentation.
Appeal to state insurance board if that doesn't work.
They will deny until you get tired of appealing and then they win. Don't let them win.
 
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