Resources for Proper Payment and Appeals
Friday, October 28, 2022
With recent major changes that were made to the evaluation and management (E/M) services Current Procedural Terminology CPT® code set, some health plans are disputing E/M levels for submitted claims and implementing E/M downcoding programs
that inappropriately—and often automatically, through claim editing algorithms—reduce payment for provided services.
The AMA has created a new resourceto support physician practices in navigating such payer E/M downcoding programs. The document offers examples of downcoding scenarios, sample plan communications, guidance on reviewing remittance advice to identify downcoding, and documentation tips to
support successful appeals. Also included are sample downcoding appeal letters, which are available in an editable format on the AMA website.
The AMA has created an informational survey to track health plans’ downcoding programs and further support physician practices in responding to
payer downcoding initiatives.
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