November 01, 2022
In 2021, major changes were made to the evaluation and management (E/M) services Current Procedural Terminology CPT® code set and reporting guidelines to reduce documentation burdens, simplify coding and allow physicians to spend more time with patients. Unfortunately, some health plans are disputing E/M levels for submitted claims and implementing E/M downcoding programs that inappropriately—and often automatically, through claim editing algorithms—reduce payments for provided services.
The American Medical Association (AMA) has created a new resource to support physician practices in navigating such payor E/M downcoding programs. The document offers examples of downcoding scenarios, sample plan communications, guidance on reviewing remittance advice to identify downcoding and documentation tips to support successful appeals. Also included are sample downcoding appeal letters, which are available in an editable format on the AMA website.
If your practice has been subject to payor downcoding, please consider completing this informational survey so AMA can to track health plans’ downcoding practices. Results will be used to help support physician practices in responding to payor downcoding initiatives.