At any time question why often when you get reimbursed for a assert, the insurance plan firm has “transformed the code to a much more suitable code for payment”? You submitted the claim as a 99214 but they paid you for a 99213 or even even worse, a 99212. This practice is called downcoding.

Do you have to settle for it? Perfectly in some situations you do. A great deal will rely on the contract that you have with the insurance policies carrier. Some contracts will only make it possible for companies to monthly bill specific cpt codes. In that situation, they can change a billed code to a single of the authorized codes. Or the contract could specify that you can only invoice a sure variety, or share of statements at the larger codes.

But in some cases an insurance policies carrier will just downcode your claim and it is not due to agreement requirements. In that circumstance you can charm it. We not long ago experienced a declare that the coverage carrier downcoded a 99214 to a 99213 and informed us that they only enable a company to monthly bill a 99214 each and every 6 months for a individual. That is ludicrous. How can that guideline utilize to any affected person?

At times we just have to remind the insurance policies carriers that the doctors are the kinds who identify the patient’s demands. In this scenario we despatched in business notes and a letter advising them that we have been interesting the processing of the assert. The doctor had fulfilled the requirements to justify the billing of a 99214 and their “rules” ended up inappropriate. We been given payment for the variance about 10 days later on.

So if you are getting challenges with your statements staying downcoded, and they are not due to deal technical specs, you really should enchantment. Do not just take what the coverage provider does. That is what they are counting on. Just consider of how considerably money they help save on the providers that do not do anything at all about it.

Copyright 2008 – Michele Redmond