preclude Down Coding By insurance fellowships On medical Claims

preclude Down Coding By insurance fellowships On medical Claims Ever wonder why sometimes when you get reimbursed for a claim, the guarnatee company has "changed the code to a more standard code for payment"? You submitted the claim as a 99214 but they paid you for a 99213 or even worse, a 99212. This practice is called downcoding.

Do you have to accept it? Well in some cases you do. A lot will depend on the compact that you have with the guarnatee carrier. Some contracts will only allow providers to bill determined cpt codes. In that case, they can change a billed code to one of the allowed codes. Or the compact may specify that you can only bill a determined number, or percentage of claims at the higher codes. But sometimes an guarnatee carrier will just downcode your claim and it is not due to compact specifications. In that case you can request for retrial it. We recently had a claim that the guarnatee carrier downcoded a 99214 to a 99213 and told us that they only allow a provider to bill a 99214 every 6 weeks for a patient. That is ludicrous. How can that guideline apply to any patient? Sometimes we just have to remind the guarnatee carriers that the doctors are the ones who determine the patient's needs. In this case we sent in office notes and a letter advising them that we were provocative the processing of the claim. The doctor had met the requirements to explicate the billing of a 99214 and their "guidelines" were inappropriate. We received payment for the disagreement about 10 days later. So if you are having problems with your claims being downcoded, and they are not due to compact specifications, you should appeal. Do not just accept what the guarnatee carrier does. That is what they are counting on. Just think of how much money they save on the providers that do not do whatever about it. Copyright 2008 - Michele Redmond preclude Down Coding By insurance fellowships On medical Claims