Maximize Reimbursement with Payor Downcoding and Claim Denials Prevention in 2025

Event Materials (Key Required)

Course Description

Payer downcoding occurs when the payer assigns a lower-level code to a medical service or procedure than what was submitted to the payer for the patient without review of the medical record. This results in lower reimbursements that can significantly impact a physician’s bottom line. Providers can take certain steps to avoid payer downcoding, such as using the correct code set. Providers and payers are required to use standard code sets designated by the U.S. Department of Health and Human Services (HHS) such as CPT’s evidence-based codes, which accurately encompass the full range of health care services.

The American Medical Association (AMA) created new Evaluation and Management (E/M) guidelines, to reduce the documentation burdens placed on providers. Following the changes, several payors began implementing algorithms, within their systems, that inappropriately down-coded claims, causing payment reductions. To the frustration of providers, payers are increasingly implementing E/M downcoding programs that inappropriately reduce payment for claims billed. Often, these reduced payments, go un-noticed, as staff is looking for full denials, and not claim payment reductions.

Most often, a claim is down-coded because the payer disputes the use of a higher-level E/M code or states that the diagnosis code submitted on the claim does not warrant a high-level service code. An increasing number of payers are downcoding claims automatically using software algorithms, without first requesting and reviewing clinical records. Inappropriate downcoding by payers can significantly reduce revenue for physician practices, especially when it becomes routine or when a physician becomes subject to global prepayment review. Facilities will need to implement guidance to staff on how to review remittance advices to identify downcoding, provide proper education to staff on documentation guidelines, and educate staff on how to obtain successful appeals when downcoding occurs.

Learning Objectives

• Learn how to discover if your claims are being paid at a lesser value than what was submitted (down-coded)
• Review the examples of downcoding scenarios
• Understand how to appeal these claims with sample appeal letters
• Review Sample downcoding-appeal letter (DOC)
• Effective documentation tips to support successful appeals
• Issue tips for educating providers on key documentation guidelines to avoid payor downcoding

Areas Covered in the Session

• E/M documentation guideline changes 
• Documentation 
• “MEAT” and “TAMPER”approach 
• Specificity-Asthma 
• Specificity – Diabetes 
• E/M Changes-EMR 
• Payer Downcoding 
• Payer Downcoding Programs 
• Data Analytics 
• Algorithms 
• Examples of payer Downcoding 
• Example 1: Emergent primary care physician (PCP) office visit with high level of MDM Scenario
• Example 2: Office visit with moderate level of MDM, diabetes Scenario 
• Payer Policies 
• Payor Verbiage in Contracts 
• New Verbiage-Contracts 
• Claims Denials/ Improper Payments 
• Specific Payor Policies 
• Example of specific payer policies-Wellmark 
• Examples of specific payor policies-Cigna 
• Examples of specific payor policies-UHC 
• Examples of specific payor guidelines-Anthem 
• Examples of specific payer policies- MODA Health 
• AMA Policy on Downcoding 
• Recognizing Downcoding 
• Recognition-What Your Facility Can Do 
• Appeals 
• Appeal Checklist 
• No Surprises Act (NSA) 
• Prior Authorizations 
• Prior Authorization Denials 
• Current Cases and Examples 
• Facility Actions - Next Steps for Facilities 

Suggested Attendees

• Healthcare Providers or Physicians
• Administrators
• Medical Billers
• Claims Coders
• Revenue Cycle Managers
• Billing Staff and Companies
• Physicians and Other Providers
• Healthcare Consultants
• Compliance Officers
• Office Managers
• Practice Manager
• Chief Financial Officers
• In and Out of Network Providers
• Medical Billing Companies
• Hospitals and Facilities
• Insurance Companies
• Healthcare Attorneys

About the Presenter

Susan Rohde, RHIT, CCS-P, CPC, has more than 28 years of experience in health care industry with an emphasis in coding, health information management, medical necessity and documentation. Susan is currently serving on the education committee for NSCHBC. Her other memberships include AHIMA, NDHIMA, AAPC, NSCHBC, HFMA and MGMA. She specializes in reviewing documentation for accurate reimbursement within Evaluation and Management (E/M) and all surgical specialties, including Interventional Radiology, Anesthesia, Neurosurgical, and Orthopedics, for both ICD-10-CM and CPT codes. Susan helps navigate the ever-changing coding and documentation world and can help your organization in maximizing its coding potential via proper documentation, provider and coding staff education, and understanding of guidelines and regulations.

Additional Information

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to hear clearly

For more information, you can reach out to the below contact:

Toll-Free No: 1-302-444-0162

Email: care@skillacquire.com 

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