The ACR has received an increasing number of complaints about commercial payers downcoding payments to rheumatologists for evaluation and management (E/M) services. The ACR’s Insurance Subcommittee continues to push back on payers and to advocate for fair and appropriate reimbursement, with support from an important ally: the American Medical Association (AMA).
AMA policy states: “Payer downcoding practices do not accurately reflect the updated E/M guidelines and/or may inappropriately use diagnosis codes as a proxy for the level of care provided. In addition, automatic downcoding programs place onerous administrative burdens on practices forced to fight for appropriate payment rates.”
The AMA has created resources to assist practices in the fight against downcoding. AMA guidance on payer evaluation and management (E/M) downcoding programs provides information and tools to assist practices in recognizing and fighting downcoding to help ensure payment for downcoded claims, even after the fact.
ACR members are encouraged to review and use the AMA resources as needed to deter inappropriate payer downcoding. ACR staff are also available to provide assistance and can be reached at [email protected].
