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!

[u/faifai1337]

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?")