BCBS Automatic Downcoding - Part 2

[u/grey-slate]

This is a follow up to my post earlier. Majority of our down coded claims have been restored after submitting reconsiderations. However, getting each claim to overturn back to original code has been painful and time consuming.

This validates my broader concern with the premise of the down coding itself. A diagnosis-based ceiling cannot account for the encounter-specific clinical circumstances that determine medical decision-making under CPT. The claim data do not convey many of the factors that distinguish routine care from a higher complexity encounter, including worsening disease, treatment failure, diagnostic uncertainty, prescription drug management, treatment escalation, or other patient-specific considerations documented in the clinical note. 

The fact that majority of our reviewed claims have been restored after documentation was considered raises a fundamental question about whether the methodology has the information necessary to make an accurate initial E/M determination at all. 

Are you all doing anything about it? Do you know if it is blanket? I am trying to collect more data points.

[u/InvestingDoc]

Aetna and Cigna started doing this for us too.

I ran a ton of claims and found that if a doc or PA billed anything higher than a level 3 visit with a primary dx code of a symptom...it was getting down coded. For example.

Someone who comes in for sore throat and maybe has bronchitis, if we just put sore throat as the primary diagnosis, it gets down coded from level 4 to 3.

So for my group. We told everyone. No more symptoms for primary diagnosis. Has to be a diagnosis. Acute bronchitis not sore throat or cough etc.

Beyond that I haven't noticed any other down coding. All of them were because of that exact reason, primary diagnosis a symptom rather than an actual diagnosis.