decisionhealth Newsletters, Part B News - 2019 Issue 10 (October)
If payers downcode lots of your E/Ms, check your work – and fight if you’re right
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Article Overview
This article discusses payer downcoding of evaluation and management claims and how practices can assess whether the denials reflect documentation issues, coding concerns, or payer processing problems. It is aimed at physician practices, coders, and billing teams that need to understand when to review records internally, when to consider an appeal, and how payer edits and review processes can affect reimbursement and audit risk.
Why This Topic Matters
Repeated downcoding can reduce revenue, signal documentation gaps, or indicate a broader payer review pattern. Understanding the general reasons claims are adjusted and the options for internal audit, appeal, or further inquiry helps practices protect reimbursement while monitoring compliance risk.
What You Will Learn
- How to think about repeated payer downcoding of E/M claims
- What kinds of documentation issues can lead to claim review
- Why internal audits may be useful before appealing denials
- When payer edits or review processes may affect E/M reimbursement
- General considerations for deciding whether to appeal downcoded claims
Who Should Read This
- Physician practices
- Medical coders
- Billing staff
- Compliance staff
- Practice managers
Codes Discussed
Modifiers Discussed
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