Many payers, including some state Medicaid programs, use proprietary coding software that include edits for denials or reductions in levels of evaluation and management (E/M) services when reported with certain diagnoses. An E/M code is selected based on the key components (history, physical examination, and medical decision making) performed or when counseling or coordination of care is greater that 50% of the face-to-face visit. These guidelines are clearly outlined in Current Procedural Terminology (CPT®), which recognizes that there can be variation in the treatment of a patient with a particular diagnosis and therefore, there are no requirements for the reporting of a certain level of code based on a diagnosis or symptom.

If payer downcoding based on diagnosis is occurring in your practice, you should take the following steps. Prior to appealing a claim, review the documentation to be certain the level of service billed is clearly...

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