Author Topic: Down-Coding  (Read 1466 times)

Questhrr.com

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Down-Coding
« on: February 27, 2016, 12:42:21 PM »
Hello All,

I have a situation where a PIP payer down-coded an office visit from 99204 to 99201. 

Now, please understand that as I don't do coding and billing, and so I'm a unfamiliar with anything to do with coding.  However, I looked these codes up and 99204 seems to be for medical treatment from moderate to severity with up to 45 minutes with the provider.  Whereas, 99201 is for the least possible minor treatment (equivalent to treating an insect bite) with only up to 10 minutes with the provider.

The payer states that the provider's notes did not merit the high level code 99204, so they down-coded it to 99201.

So, my thinking on this is that the payer is misrepresenting the medical services in order to render a much lesser payment which is in violation of 18 U.S. Code 1035 - False statements relating to health care matters.

Does anyone else have any experience with this or input on this matter?

Thanks,

Kevin

kristin

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Re: Down-Coding
« Reply #1 on: February 27, 2016, 01:15:47 PM »
Without seeing the actual treatment note, it is impossible to say what level the visit should have been billed at. The payer may be doing what you said, or, the note may lacking what is needed to achieve a 99204, which would not surprise me in the least. There is a saying..."if it wasn't documented, it wasn't done". Meaning the provider may well have done everything need to achieve a 99204, and spent enough time with the patient, but if the note does not reflect that, it will be down coded to what it DOES reflect.

Achieving a 99204 requires A LOT of documentation, and it has to be pertinent to the presenting issues, and stand on its own. I audit treatment notes all the time, and I constantly see 99204's and 99205's(the highest new patient level) being billed, and the notes are only good enough for a 99201 or 99202. If you can get a redacted copy of the note, with all PHI removed, I can tell you more, but without it, it is anyone's guess to whether the payer is right or wrong here.

Questhrr.com

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Re: Down-Coding
« Reply #2 on: February 27, 2016, 02:53:32 PM »
Hello Kristin,

Thank you so much for sharing your knowledge.  I will ask the provider for the notes.

Thanks,

Kevin

PMRNC

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Re: Down-Coding
« Reply #3 on: February 28, 2016, 07:34:43 PM »
Quote
Now, please understand that as I don't do coding and billing, and so I'm a unfamiliar with anything to do with coding.  However, I looked these codes up and 99204 seems to be for medical treatment from moderate to severity with up to 45 minutes with the provider.  Whereas, 99201 is for the least possible minor treatment (equivalent to treating an insect bite) with only up to 10 minutes with the provider.

The payer states that the provider's notes did not merit the high level code 99204, so they down-coded it to 99201.

So WHO billed the charges? Hopefully it was not you as you already stated you thought it was the wrong code.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Questhrr.com

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Re: Down-Coding
« Reply #4 on: February 29, 2016, 12:01:51 PM »
Hello Linda,

No, it was not me, I don't do billing.  I'm not sure who the biller is for this provider.