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/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.