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.