Healthcare Business Management Association (HBMA) continues to raise concerns about the growing use of payer automatic downcoding policies. Under these policies, payers reimburse CPT codes at a lower level than providers submitted without reviewing the patient’s medical record to determine whether the billed code was appropriate. Triggers for this auto-downcoding can include submission of nonspecific diagnosis codes, and provider coding patterns that demonstrate higher than “normal” E&M levels. Payers are developing AI tools to drive this downcoding initiative. As a result, providers must devote substantial financial and administrative resources to appealing downcoded claims. HuTech is monitoring this closely for our RCM clients.
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