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Background

Downcoding occurs when a payer automatically reduces a submitted claim to a lower E/M level, often via automated edits and without chart review, resulting in underpayment. Payers typically justify this by disputing the high-level code selection or claiming the diagnoses don’t support it. Increasingly, software algorithms apply these reductions before any records are requested. When done routinely, or under global prepayment review, inappropriate downcoding can significantly erode practice revenue.

National spotlight

This practice is increasing and gaining media attention, with NBC News recently reporting how physicians feel insurers are applying “guilty until proven innocent” logic by reducing claims first and forcing doctors to fight for full payment later. The article highlights mounting tension between clinicians and payers, particularly as these edits are implemented without transparency or consistent clinical standards.

NBC News — “Guilty until proven innocent: Inside the fight between doctors and insurance companies over ‘downcoding’”

Who’s doing it

Most national payers now run automated claim-review programs. Recent Cigna and Anthem initiatives specifically target high-level E/M visits and may unilaterally pay at a lower level, often without prior chart review, unless the claim is appealed. Payers may also reduce payment without changing your billed code and without notice. The only signal can be the paid amount or a cryptic remittance message.

What to watch for

• Payments align with a lower E/M level than billed. Compare allowed/paid amounts to your fee schedule.
• Not a uniform cut. Variability across payers, patients, and dates underscores the need for diligent claim-by-claim review.
• Remittance clues. Look for adjustment/remark codes signaling a level change (e.g., CO150, M85, N610, CARC 186), some payers won’t change the billed code, only the paid amount.

Why This Matters for GI

• High clinical complexity is routine. Managing IBD flares, pancreaticobiliary disease, cirrhosis, and GI bleeding risk often supports higher level E/M 99214/99215. Blanket downcoding ignores this nuance.
• Added administrative burden. Teams must monitor submissions/remittances, assemble and complete appeals with records, and manage delayed cash flow.
• Real revenue at stake. The Medicare national payment gap between 99213 and 99214 is approximately $36 and 99213 and 99215 is approximately $87 (varies by year/locality), which compounds quickly across a practice.
• Incentive to under code. Physicians may avoid justified level 4/5 billing to dodge payer disputes, undermining accurate reporting.
• Access risks for complex patients. Smaller GI groups face disproportionate strain,  potentially limiting availability for high-acuity care.
  

Bottom Line for GI Physicians

Downcoding threatens fair reimbursement for complex GI care. Stay vigilant, appeal when appropriate, and report issues to advocacy@asge.org so we can ensure coding integrity and protect patient access to specialized GI care.