Downcoding & Blending

Some payers have decided to 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.

AAFP believes that abiding by the principles of CPT means that reimbursement 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 reimbursement.