Have your billers appeal every level 3 billed as a starting point and would have your practice manager reach out to them or draft a letter explaining that it is inappropriate and doesn't follow CMS guidelines.
No it is for a level 4 visit which can be billed by time but ALSO by complexity--it has nothing to do with the number or severity of codes. For example I could code a 'cough', review/interpet a CT scan,m look at 3+ labs, and start a prescription medication for it and that is a level 4 visit right there.
I would argue that the coding guidelines from CMS do not specify certain codes that do not qualify as level 4 visits and that if they disagree with your coding notes they need to point out what elements it failed to reach in order to be paid at the level billed.
When you are looking to bypass a software edit an insurance company implements it absolutely comes down to specificity and severity of diagnosis. Especially if you are only reporting one diagnosis. The claim edit software is not taking documentation into account when it is down coding the services. The goal should be to get paid on one claim submission and not to appeal dozens.
I agree in principle but this is a predatory and inappropriate practice that should be challenged. These parasites are leeching money out of the healthcare system they should at least be held accountable to the rules they helped invent. Hell if this is widespread enough we could create a class action though I have not personally seen this problem.
Editing a code without taking documentation into account does not sound like it should be legal...
That is not what I proposed. The documentation always needs to support the service. My experience is that physicians will give a generic diagnosis such as diabetes as a diagnosis to be billed, but will not be specific as to if it is Type 1 or Type 2. They will not specify if there any complicating factors or additional issues such as neuropathy. Being as precise as possible with the diagnosis coding on the initial claim will bypass these edits.
Ok but if you bill as diabetes and your documentation shows that it is not controlled / at goal, you reviewed two labs and managed an Rx it shouldn’t matter whatsoever what diagnosis is billed… that is a 99214
OP isn't being audited though, they are having a computer render a verdict in their favor automatically without any actual review which is wrong.
Yeah THAT is what I am saying should not be legal… if this is truly as OP describes it sounds like they are downcoding based on ICD and not even reviewing documentation?
Oh look an administrative parasite sucking the life out of the system came to tell us that we need to do more work to get paid less and make sure it gets its piece for doing 'work' too. Thanks for that insightful comment, do I need to go bring the Aetna CEO some coffee too?
Is that what I said? I said that more accurate information needs to be provided on claims in order to get paid correctly. It wasn't your service that was being down coded it was for someone else. Hopefully my feedback helps that person get paid in the future.
Yeah we hear what you're saying but it really shouldn't work that way and you're kinda condescending about it.
Automating the process is illegal for the sole purpose of downcoding outside of defined criteria (ie it is ok if mutually excluded codes are billed to automatically trash one of those but not to pick a less expensive code by default). The AMA won a lawsuit on this 20 years ago and more are ongoing.
Totally respect whatever you choose but it might not be impossible to fight them with fire.
