Which of the following is not a potential reason for downcoding?
A) The insurance carrier does not cover the services included on the claim.
B) The coding system used by the insurer does not match that used by the provider.
C) A workers' compensation carrier converts a CPT code to the lowest-paying code in the system.
D) The payer discovers that documentation does not back up the level of code used.
E) The provider uses a HCPCS code the insurer does not recognize.

Question

Quizplus · Accepted Answer

Downcoding occurs when insurance carriers or payers adjust the codes submitted by healthcare providers to lower-paying codes, but it is not because the services are not covered. It typically happens due to discrepancies in documentation, coding mismatches, or unrecognized codes, not because the service itself is not covered by the insurance.

Which of the Following Is Not a Potential Reason for Downcoding