Ever marvel why typically whenever you get reimbursed for a declare, the coverage firm has "changed the code to a more appropriate code for payment"? You submitted the declare as a 99214 even so they paid you for a 99213 and even worse, a 99212. This follow far-famed as downcoding.
Do you must settle for it? Well in some circumstances you do. Loads will flexible joint on the contract that you've with the coverage service. Some contracts will entirely enable providers to bill sure cpt codes. In that case, they'll change a beaked code to one of many allowed codes. Or the contract could specify which you can entirely bill a sure quantity, or proportion of claims on the greater codes.
But typically an coverage service will simply downcode your declare and it isn't attributable to contract specs. In that case you possibly can enchantment it. We not too long ago had a declare that the coverage service downcoded a 99214 to a 99213 and instructed us that they entirely enable a provider to bill a 99214 each 6 weeks for a affected person. That is ludicrous. How can that guideline apply to any affected person?
Sometimes we simply should prompt the coverage carriers that the docs are those who decide the affected person's wants. In this case we despatched in work notes and a letter advising them that we had been exciting the processing of the declare. The doc had met the necessities to justify the charge of a 99214 and their "guidelines" had been inappropriate. We obtained fee for the distinction about 10 days later.
So if you're having issues on with your claims being downcoded, and they don't seem to be attributable to contract specs, it's best to enchantment. Do not simply settle for what the coverage service does. That is what they're relying on. Just consider how a stack cash they save on the providers that don't do something about it.
Copyright 2008 - Michele Redmond
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