| Ever wonder why sometimes when you get | | | | they only allow a provider to bill a 99214 every 6 |
| reimbursed for a claim, the insurance company has | | | | weeks for a patient. That is ludicrous. How can that |
| "changed the code to a more appropriate code for | | | | guideline apply to any patient? |
| payment"? You submitted the claim as a 99214 but | | | | Sometimes we just have to remind the insurance |
| they paid you for a 99213 or even worse, a 99212. | | | | carriers that the doctors are the ones who |
| This practice is called downcoding. | | | | determine the patient's needs. In this case we sent in |
| Do you have to accept it? Well in some cases you | | | | office notes and a letter advising them that we were |
| do. A lot will depend on the contract that you have | | | | appealing the processing of the claim. The doctor had |
| with the insurance carrier. Some contracts will only | | | | met the requirements to justify the billing of a 99214 |
| allow providers to bill certain cpt codes. In that case, | | | | and their "guidelines" were inappropriate. We received |
| they can change a billed code to one of the allowed | | | | payment for the difference about 10 days later. |
| codes. Or the contract may specify that you can | | | | So if you are having problems with your claims being |
| only bill a certain number, or percentage of claims at | | | | downcoded, and they are not due to contract |
| the higher codes. | | | | specifications, you should appeal. Do not just accept |
| But sometimes an insurance carrier will just | | | | what the insurance carrier does. That is what they |
| downcode your claim and it is not due to contract | | | | are counting on. Just think of how much money they |
| specifications. In that case you can appeal it. We | | | | save on the providers that do not do anything about |
| recently had a claim that the insurance carrier | | | | it. |
| downcoded a 99214 to a 99213 and told us that | | | | |