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Downcoding and Blending
Some payers either downcode or blend payment rates for evaluation and management (E/M) services. Downcoding is when a physician files a claim that is automatically processed at a lower rate (e.g., a 99215 may be downcoded to a 99214). Blended rates occur when a payer pays the same contracted fee for a group of E/M services. For example, a physician may be paid the same rate for 99213, 99214 or 99215 services.
Our Stance
AAFP believes that abiding by the principles of CPT means that payment for covered services should be based on the codes documented and billed by the physician. Automatic, unilateral downcoding contrary to CPT is not acceptable. Read the full policy on coding and payment.
Make Your Voice Heard
- Write to your payers to express your opinion about the E/M coding utilization shift. Download a template letter (3-page Word file; About Downloading), personalize it and send it to your payers.
- We want to hear about your experiences. Submit a health plan grievance or view grievances submitted by other members. (Members Only)
Payment
