Aetna does not automatically change a dentists submitted procedure code to a less complex or lower-cost code, subject to the following: (a) A submitted code may be changed when a professional review of the submitted charges and supporting clinical information such as x-rays, photographs, periodontal charting, narratives, and treatment notes, indicates that the original coding may have been inappropriate; and (b) Aetna will adjudicate claims in accordance with the terms, exclusions and limitations of a member s dental benefits plan, including, but not limited to, any contractual alternate treatment/alternate benefit provisions (ABP). Tools for proper payment & appeals - American Medical Association Upcoding involves overbilling a patient, while downcoding is the reverse of upcoding. To help physicians understand health insurer overpayment recovery requests, the AMA created theOverpayment Recovery Toolkit(PDF). dental benefit plans allow the dentist to additionally bill the patient for Upcoding disadvantages patients as they are forced to pay for services they never received. Downcoding occurs when an insurance company finds there is insufficient evidence on a claim to prove that a provider performed the coded medical services. If you have any questions We're are here to help Social Security: 3 Ways a Spouse Can Claim Benefits Frequently Asked Questions | Aetna Dental D. patient determine is clinically appropriate, not by plan compensation. You might . We have shown the inappropriateness of these downcoding edits in specific actions we have handled for clients. contract agreements.". This greatly dents the patients' pockets. For more about Betsy visit www.betsynicoletti.com. Submit COB claims Payment estimator and fee schedule Estimate how much your patients will owe for an office visit. dictate the level of care reported by the dentist, only to provide some Risk of non-compliance due to financial inconsistencies during audits, Reputational damage associated with lawsuits, Loss of revenue to healthcare facilities related to downcoding. The insurance company reduces or removes these codes. The Dangers of "Downcoding" in Emergency Medicine - HFMA policies, even during the contract negotiation process. In addition, carrier coding methodologies should be made readily purchaser and the payer in a manner that does not impact the doctorpatient relationship, it would help clear the air. You may choose a letter based on the nature of the denial you are experiencing, and if it exactly describes the inappropriate denial simply complete the blanks with the names of the payer in question, and submit your appeal. This process will be necessary for each IP address you wish to access the site from, requests are valid for approximately one quarter (three months) after which the process may need to be repeated. One of the most effective ways to detect and eliminate upcoding and downcoding is to perform periodic internal audits. Instead, the physician simply receives lower reimbursement rom the insurance providor. Many carriers typically do not disclose their bundling or downcoding Follow the intent of the CPT code descriptor in that they should be designed to reasonably relate the intensity of hospital resources to the different levels of effort the code represents. May 11, 2022 Tags: Coding Denials Upcoding and downcoding are flip sides of the medical coding coin, and both can have seriously detrimental effects for healthcare providers and patients. How to Pay Your Houston Water Bills Online Hassle-Free, How to Remove My Case From The Internet Instantly, How to Recover Your Forgotten Workday Password Hassle-Free, Sending Money to an Inmate Has Never Been Easier, Credit Card Dispute Letter Template That'll Get Your Money Back, Submit a Hotline Complaint | Office of Inspector General | Government Oversight | US Department of Health and Human Services, Contact the Health and Human Service Office of the Inspector General at, Report to the Centers for Medicare & Medicaid Services. This is also known as undercoding and usually results from insufficient documentation. PDF appendix e - American Association of Oral and Maxillofacial Surgeons Bundling is defined by the ADA as "The systematic combining of Bundling: The NCCI edits do not apply to commercial claims, do not apply to inpatient claims, and do not set industry standards for billing and payment of commercial claims. Downcoding is a practice of third-party payers in which the benefits code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in . Downcoding is when dental plans use a procedure code different from the one submitted to determine a benefit in an amount less than that which would be allowed for the submitted code. Downcoding is defined by the ADA as "A practice of third-party payers permit the clinical differentiation required for many dental procedures. They have also asserted that charges for items such as venipuncture should be included in the charges for laboratory tests or that saline solution should be included in the charges for medications. the explanation of benefits is received. accompanied by a set of bitewing X-rays if they are to be used as an The downcoding medical definition is when a provider codes a diagnosis or procedure at a lower level than what was actually performed. Another area of confusion is the practice of some third party payers to Pulp capping is a procedure in which the exposed or nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin. The sample CPT modifier 25 template letter can help practices dispute improper payment denials of E/M services correctly billed with modifier 25. If the dentist proposes a fixed bridge replacing teeth #s 19 and 20, and teeth #s 28-32 are also missing, the benefit amount will be that of a removable partial denture if appropriate to replace all the missing teeth in the arch. Health plans have instituted a wide range of policies and proceduresranging from claim edits to record requests to global payment reductionsto address perceived misuse of CPT modifier 25. Aetna Inc. and its subsidiary companies assume no responsibility for any circumstances arising out of the use, misuse, interpretation or application of any information or other material provided by EDI Health Group (EHG). Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. the reporting of dental services in accordance with the contract that a lower level of care was needed or should have been provided. They should not be based on physician resources. If the code that is documented is at a lower level of complexity or cost than what is documented, it is called downcoding. All content on CodingIntel is copyright protected. Learn upcoding and downcoding with these examples. instances of concern to dentists are when procedures which are coverage determination guidelines and covered procedures. This resource, "Knowing your overpayment recovery rights" (PDF), offers information on the responsibilities of health plans and the rights of physicians provided by many states laws and regulations. It uses its influence to fight dubious healthcare facility officials to ensure you get the justice you deserve. I am requesting that this "policy" be reviewed and benefits be allowed since as a board certified. Use of the GK and GL modifiers allows the DME MAC to automate the downcoding at the time of the initial determination. quadrant. There is no disagreement about the right of a plan purchaser and the Payers may also pay benefits for procedures as a result of applying an Result in coding decisions that could be verified by other hospital staff members, as well as outside sources. Get timely payments with electronic coordination of benefits (COB) when a patient is covered under more than one insurance plan. Fighting upcoding and downcoding is challenging, as they are hard to detect, especially if they are well executed from the beginning. Is Your Dental Bill Higher Than Expected? We believe this is inappropriate according to the official guidelines for outpatient coding. Tell us the date of your visit, what you were treated for, and where you were treated. Reporting you conducted an Ultrasound complete exam (CPT code 76700), yet you conducted an Ultrasound abdomen limited exam (CPT Code 76705). Most patients do not understand the CPT Codes assigned to their diagnosis and treatment. In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. submission of code D4341 when only one to three teeth are treated in The service requested is not covered under the plan for the dental care of a specific condition, but an allowance up to the amount of an alternate covered service(s) is available. At What Age Do Retired Workers Claim Their Social Security Benefit As a result, most complaints are unaddressed, considering upcoding and downcoding are inside jobs. All Rights Reserved to AMA. Coders and providers (rightly) worry about upcoding, or coding at a "higher level" than supported by documentation or medical necessity; however, "downcoding," or coding at a level lower than the level or service supported by documentation or medical necessity, is equally damaging, from a compliance . 4 MIN READ Andis Robeznieks Senior News Writer Bookmark Print Page Payers have been wrongly cutting payments to physicians for evaluation-and-management (E/M) servicesoften automatically through the use of claim-editing algorithms. The AMA offers resources to help physicians secure correct claims payment from health plans, navigate the overpayment recovery process and appeal incorrect payments. patients have no way of knowing what the reimbursement will be until This is why regular checking of EOB against procedures performed is crucial to accurate billing and receiving optimal reimbursement. Claiming Social Security Early Will Slash Your Monthly Benefit for Life Downcoding also typically reduces the cost of a claim. pretreatment estimates that a treatment plan should be To the extent. and a panoramic film is particularly useful for those patients who are to