New resources to help with health plan E/M downcoding

The American Medical Association (AMA) has published a new resource to help physicians navigate health plan E/M downcoding programs and retain proper payment. In the wake of the 2021 changes to E/M coding, some health plans have implemented downcoding programs that use claim-editing algorithms to automatically reduce payment for E/M services, sometimes inappropriately.

The AMA document offers examples of downcoding scenarios, sample plan communications, guidance on reviewing remittance advice to identify downcoding, and documentation tips to support successful appeals. For example, to identify payers with automated downcoding, the AMA recommends physicians look for language indicating that a health plan uses software programs for "claims edits" or "reviews" of claims. The organization also warns that identifying individual claims that health plans have downcoded can be difficult because some plans simply pay the lower rate without even changing the billed code. Physicians should therefore be on the lookout for this type of language:

• "Payer deems the information submitted does not support this level of service,"
• "Subjected to review of physicians evaluation and management services,"
• "Payment based on appropriate level of care," and
• "Level of care change adjustment."

This AMA page includes an E/M downcoding appeal letter template in an editable format ("E/M downcoding letter" under the "Evaluation and management (E/M) downcoding subhead).  You can also share your experience with private payer downcoding via an informational survey. 

— Kent Moore, AAFP Senior Strategist for Physician Payment

Posted on Nov. 8, 2022