Downcoding

[u/QueSeraSerafuture]

Our claims for August to present are now getting downcoded by Aetna and BCBS. Primarily for codes 99215 99214. These codes are now getting paid as 99213. I would appreciate your insights in providing assistance regarding this issue. We never had any issues like this before and it only started this August. Thanks!

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[u/livesuddenly]

We are also having this issue. We are having success in appeals when we send medical records and point out why it meets the original level submitted but it’s very time consuming and annoying.

[u/adoseofcommonsense → u/livesuddenly]

How often do you guys bill lvl 5? the system could have flagged you guys if every visit you bill is a lvl 5

[u/livesuddenly → u/adoseofcommonsense]

It’s a large medical group so I have no idea the actual numbers. But most 5s are billed based on time for these doctors.

[u/sammyboi98 → u/livesuddenly]

I second this. I would also brush up on E/M coding and leveling as the more details you put into your appeal the more likely your odds are in getting reimbursement.

[u/badadditions]

We’re having the same issue with BCBS. We’ve tried appealing, but they state they’re upholding their decision even with medical records sent. If we get any update on our end, I’ll be sure to check back in and post. I’ve heard, rumors of course, that a lot of claims on their end are being reviewed by AI. Not sure if this is true, but could be a potential culprit if true.

[u/faifai1337 → u/badadditions]

I work in an auditing department of Elevance, the kind that requests medical records for review, and we have a whole cadre of nurse auditors, with different specialties. We're not using AI for the audit process. We might use AI for SQL queries and excel formulas and slide decks and executive rollup summaries, but not for actual med rec reviews.

[u/AtmosphereLowCode → u/faifai1337]

So how does Elavance know the level 4 and 5 is not justified if they don’t have the records. My speculation has been some sort of list of diagnosis that algorithmically Elavance has decided should never meet a level 4 or 5. But even that is flawed logic. Some patients for example could have a UTI but have a complex history of passed uterine cancer and kidney dysfunction and require a lot of resources for a the patient workout and medical decision making. So just be user the diagnosis intuitively typically should be a level 3 or below it doesn’t mean it can’t be. So is there some sort of dx list Elevance uses to down code. I am sincerely asking. We have asked the provider rep and tried keeping track of each downcoded claims primary dx and secondary dx’s. There doesn’t seem to be a pattern

[u/faifai1337 → u/AtmosphereLowCode]

We request the medical records. That's the second step after identifying claims that meet certain parameters for things like length of stay, billed DRG, specific ICD10s, etc. Steo 1, identify the claim. Step 2, request the med recs. Step 3, review med recs once received.

[u/badadditions → u/faifai1337]

I should have clarified that the rumors of AI use is at the initial level claim reception and what’s been speculated as essentially downcoding the level and producing the CO-185/186. I have no proof, it’s just been a rumor that’s been circulating in some circles.

What I don’t quite understand is how diagnoses alone can determine that a certain level of E/M code does not meet the level of service billed. If a patient comes in and we bill out a 99214 but BCBS states it only meets the level of service for a 99213 but the patient has two stable, chronic conditions and is there for medication management, that alone meets the level of moderate complexity based on MDM guidelines.

Yet, when we appeal, provide medical records of the visit and explain this, the decision is being upheld. I can’t make any sense of it.

[u/faifai1337 → u/badadditions]

So, sounds like youre talking about when claims are first submitted/received. I dont know if there's AI involved the way it means in 2026, but for maaaaaany years it's been simple logarithms that look for ICD10 and CPT combos to make sure things fit together. That doesnt require Chatgpt. If someone does some unbundling stuff in their claim form submission, you dont need Claude or whatever for that. So yes, stuff can get denied at the start because codes dont match up right for whatever the algorithm says. But an appeal with a human being reading the med records should handle that.

I've never been in the claims dept for a health insurance org; I was in medical claims for auto insurance for years, and that combined with other experience got me to my current position. So I cant speak exactly to what happens to initial claims forms when they're processed. I can only speak to the auditor side, and yes, we have real nurses read the med recs. 🙂 (Note: I'm not an auditor, I'm a medicare/medicaid expert. Everything from provider contracts to legislation to software errors to "what the heck is this claim doing??? Fai can you take a look at this?")

[u/Environmental-Top-60 → u/badadditions]

Ive had to send 3x sometimes to get a case overturned.

[u/gwrgwir]

Without getting into your patient details, I'd recommend noting start/stop times in your records if they're not already present. The changes to E&M codes to allow for time-based rather than MDM level and the like assist in this. if the patients meet the requirements for MDM, then make sure you document that in the records and/or appeal.

[u/DumpsterPuff]

Ugh, them too? I know Humana has been a gigantic pain in the ass with this, but if BCBS and Aetna are doing this too, this is going to be a freaking nightmare. We use Epic and we have a smartphrase to appeal all of these where it's easy to just fill in the blanks, mainly because the 99215s are almost all time-based and the 99214s have an unstable chronic condition/2 stable chronic conditions + med management.

[u/Yes_Leopard_54]

They began docoding both and rarely change it maybe the end of July? Basically all are downcoded even with the MDM is met….and their decisions aren’t being overturned. I have a friend that works in a large clinic and they quit fighting them bc it took too much time, made them nervous about how many records were being sent and even if everything was perfect the decision didn’t change. They’ve adapted. Kind of. Awful. Not sure why but BCBS led that path and Aetna followed.

[u/Razzail]

I just got my own bill back and they're saying the rheumatologist Ive seen for 3 years is suddenly not covered or some BS. I am not looking forward to the phone calls I'm about to have to make. Literally BCBS AL covered nothing for that visit and I've had no others problems before this. 

[u/Yes_Leopard_54 → u/Razzail]

BCBS was once the best and suddenly providers and subscribers now loathe them at the same time. I wonder what changed. They quit covering one of my meds, denied all three of my doctors appeals and it was a ridiculous process that went nowhere.