Washington E-Newsletter

Evaluation and Management Coding Resources

Effective Jan. 1, 2021, changes were made to the evaluation and management (E/M) Current Procedural Terminology® code set and reporting guidelines to reduce documentation burdens and simplify coding. However, some health plans are disputing E/M levels for submitted claims and implementing E/M “downcoding” programs that inappropriately — and often automatically, through claim editing algorithms — reduce payment for provided services. Downcoding occurs when a payer changes the reported service on a claim to a lower level service than what was submitted by the physician, resulting in payment for a lower level of care than was provided.

The American Medical Association (AMA) has created a paper about these E/M downcoding programs. The document offers examples of downcoding scenarios, sample plan communications, guidance on reviewing remittance advice to identify downcoding and documentation tips to support successful appeals. Neurosurgeons experiencing E/M downcoding may want to complete a brief AMA survey. The AMA is collecting feedback to help inform its efforts to hold health plans accountable.

Click here to complete the AMA downcoding survey and here for more resources, including sample appeal letters.