Wiki WellCare Medicare downcoding

[ejthornton]

We submitted a 99214 to WellCare Medicare, and when the EOB came back they down coded it to a 99213 stating that the payer deems the information submitted does not support this level of service, can they do that? If so where I can find it documented at to be able to show my provider.

 

[csperoni]

I'm 99% certain it's in your contract. However, just because they downcoded does not mean you cannot dispute or appeal their decision.
I would carefully review the note, and if I thought 99214 was accurate, I would absolutely dispute. Include a copy of the note, any supporting documentation (like tests reviewed, etc), a copy of the AMA 2021 outpatient E/M guidelines, and a letter explaining the level for each element of MDM.