2021 E/M Code Changes

What is the problem? 

Anthem and some other payers are not paying office visits properly at times.

For some pediatricians, who have a history of using higher office visit CPT codes such as 99214 and 99215 more frequently, Anthem has been paying higher office visit codes at a lower rate (the same as 99212 or 99213).

Who is this affecting?

For some pediatricians, who have a history of using higher office visit CPT codes such as 99214 and 99215 more frequently, Anthem has been paying higher office visit codes at a lower rate (the same as 99212 or 99213).

Pediatricians who see a higher percentage of patients with complex medical needs, chronic illnesses, mental and behavioral health issues, etc. will normally have a greater percentage of these higher office visit codes and may be more at risk for this downcoding and inappropriate payment by these insurance companies.

Why is it happening?

Anthem uses a payer software program that identifies the physicians that use the higher CPT office visit codes and will base their downcoding on this data without even examining the documentation for that visit.    Anthem at times will send a 90 day notice of a change in contract to the pediatrician informing them of this payment change.

What should Pediatricians do?

If you notice that this is happening, it is recommended that pediatricians appeal any visit office codes that are not paid properly per their contract and file an AAP Hassle Factor Form (https://form.jotform.com/Subspecialty/aapcodinghotline) so that the AAP PAAC and the Ohio Pediatric Care Council can gather data on this issue.  If you have questions about proper documentation of office visits, you can consult the AAP Coding Hotline at the same website as the Hassle Factor Form.

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