Major insurer resumes downcoding E/M visits for outlier physicians  

Elevance (formerly Anthem) recently announced through their provider portal that they are restarting their evaluation and management (E/M) downcoding program in Medicare Advantage and Medicaid markets where it had been paused (Wisconsin, Indiana, Kentucky, and Ohio).

Elevance announced in 2020 that it planned to start downcoding selected E/M visit codes (99204, 99205, 99214, and 99215) on claims from physicians the insurer identified as outliers. It identified outliers by reviewing one year of data and comparing it to physicians’ peers in their geographical region.

The American Academy of Family Physicians (AAFP) advocated against Elevance’s program through in-person meetings and in writing, and Elevance paused the program in some markets to address concerns from national and state medical societies. But that pause has now been lifted.

Elevance’s claim review process assigns a risk-adjusted weight to each diagnosis code. The diagnosis with the highest supported E/M will determine the E/M code level. If the diagnosis billed on the claim doesn’t support the level of service billed, Elevance will downcode the level of service, but not below a 99203 or 99213. To avoid downcoding, physicians should use the most specific ICD-10-CM codes possible based on the conditions they address at each visit.

Outlier physicians are removed from Elevance's program on a monthly basis when they meet Elevance’s dispute review criteria (the criteria is not available outside of the company). However, the criteria is based on all impacted claims and not on a specific number of overturned claims.

Practices should review their explanation of benefits (EOB) to verify whether their claims are being impacted by the program. The remittance code varies by line of business. The message that will display on the EOB is “Evaluation and Management procedure code reduced based on diagnostic information. Disputes must include documentation.”

Practices can appeal claims downgrades through the Availity provider portal or by fax. Before submitting an appeal, review the documentation to verify it supports the level of service billed. The AAFP’s “Coding for Evaluation and Management Services: Answers to Common Questions” resource can help with this.

If you have questions regarding this program, you can contact your local Elevance network consultant. To find your consultant, select your state on this page, scroll down to “Additional Support,” and select the document that provides contact information for your state.

— Brennan Cantrell, AAFP Commercial Health Insurance Strategist

Posted on May 12, 2023