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Tips to get paid for downcoded claims

Tips to get paid for downcoded claims

A timely turnaround time in claims cycle and fair payment is what almost all the healthcare service providers in the United States look for. And in order to achieve this target downcoding is something you need to avoid.

Downcoding on the outset is a pure threat to your healthcare business as insurance companies down code the claims to save the claim amount. The payers feel it takes time for analyzing if the services are accurately performed. 

Downcoding impact on revenue

In simple terms, downcoding refers to coding at a lower level than the service supported by medical documentation. Some experts even call it as undercoding and usually arise due to insufficient documentation. 

Undercoding is a dent for your practice from a compliance point of view. If you go by the National Correct Coding Initiative (NCCI) General Correct Coding Policies, if there is an HCPCS/CPT code for describing services given, doctors must report that code instead of using comprehensive code along with other codes, which describe the services not included in the lesser comprehensive code. Basically, as a medical coder, it is required to report exact services provided and as supported by medical necessity. Anything less would lead to downcoding and further results delayed and denied payment. 

With downcoding the services performed are reimbursed at lower rates. Furthermore, the doctor or the facility won’t receive any clear cut explanation for the lower reimbursement. To avoid this revenue loss physician must be familiar with the fee schedule and match that with the amount mentioned on the EOB form.

Documentation does wonder

What can you do to prevent this? Simple, you need to pay attention to claims right from patient admission as the procedure needs to be neat, and undertaken in a meticulous manner. Remember that documentation justifying the E&M service prevents downcoding and it is the key to the claim getting reimbursed. If the service provided is missing from the patient record, it would signify that it was not done. However, never make it complicated.  Creating a template can serve this purpose. This also additionally keeps the physician reminded about the service level to be recorded.

Get help from the coders and billers:

Always keep in touch with the coders. Let them come back to you, when they feel some codes are to be changed, and when they feel something goes missing. For this, the coders and billers should be efficient enough to identify the mistakes and should have an eye for detail. Coders and billers discussing with each other help to rectify the errors before submitting the claims.

At Medical billers and coders we have garnered the respect of being one of the largest medical coding companies in the United States with over 200 in-house certified and experienced medical coders who specialize in all the medical specialities. Through our in-depth and hands-on industry knowledge and relevant expertise, we aim at serving other healthcare service providers across diverse specialities. Through our expert range of coding services, we have been delivering over 94 percent accuracy to our esteemed clients. 

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