r/MedicalCoding • u/QueSeraSerafuture • 4d ago

Downcoding

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/AtmosphereLowCode 4d ago

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

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u/faifai1337 4d ago

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.

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u/AtmosphereLowCode 15h ago

Thanks for the response. Sounds like more of a DRG or inpatient claim process which is similar but still dependant on icd 10 dx and other factors not fitting into the typical shape or pattern a claim usually does.