ASGE members may submit coding inquiries electronically to codingquestions@asge.org. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and no reports. Below is our featured Coding Question of the Month that could be beneficial to your practice.
Question:
We are seeing Cigna and other payers downcode our level 4 claims, particularly those submitted with diagnoses such as diarrhea, GERD, and IBS. What steps can we take to prevent this?
Answer:
There are several steps to take on both the front end and back end of claim submission.
On the front end:
- Enter the amounts approved in your software system for each major payer so that when the EOB is returned, the approved amount automatically comes up for each payer, making it easier to identify if the payer downcoded your claim.
- Make sure that diagnosis(es) are submitted to support at least moderate complexity. Diarrhea by itself means an acute condition and supports low complexity. If only one condition is submitted on the claim, this can trigger the payer's computer to down code the claim. Providers should be instructed to list all conditions being managed to the highest level of specificity on the assessment/impression since this is where the EHR system grabs the ICD-10 codes to assign to the claims.
- If decision making is not what drives the level of visit, then enter the total time spent in patient care in Box 19 on the claim.
On the back end:
- Look closely at each EOB, specifically at the approved amounts compared to what you billed. If different than what is expected, pull the claim, retrieve the progress note and either review or forward to the coding department for review.
- If the claim was paid incorrectly, documentation should be submitted for appeal.