rosurgery Joins Medical Coalition Opposing Evaluation and Management (E/M) Downcoding Policy

Peter J. Nelson, JD
Deputy Administrator & Director
Center for Consumer Information & Insurance Oversight
Centers for Medicare & Medicaid Services

Dear Deputy Administrator and Director Nelson,

The undersigned physician organizations are writing to inform you of a troubling policy regarding Evaluation & Management (E/M) services. It has come to our attention that several payers will implement a new reimbursement policy to review professional claims billed with E/M codes 99204-99205, 99214-99215, and 99244-99245. We have seen provider bulletins stating that the policy is in alignment with the American Medical Association (AMA) E/M services guidelines, adjusting services by one level to reflect the appropriate reimbursement when AMA guidelines are not met. This policy is in fact against AMA’s E/M service guidelines. We have seen reports that payers including Aetna, Anthem, Cigna, Humana, and Sunshine (Centene) have already begun implementing this policy.

We are concerned about this policy which implies payers will automatically adjust the E/M CPT code level until medical records are submitted to substantiate the complexity and the medical decision making (MDM) or time associated with the reported E/M visit. However, the policy does not indicate how these coding adjustment determinations are made. For example, what are the criteria which trigger such a denial? Is downcoding of E/M charges based solely on the complexity of the diagnosis codes submitted? These questions raise many concerns for us as physician notes are not typically sent with E/M visits.

Click here to view the full Neurosurgery Joins Medical Coalition Opposing Evaluation and Management (E/M) Downcoding Policy