When a claim billed for a level four office visit is paid at a level three, what should you do?

When a claim billed for a level four office visit is paid at a level three, what should you do?

• A. Submit an appeal to the carrier with the supporting documentation
• B. Rebill the claim at level three
• C. Contact the patient to adjust the charge
• D. Ignore the denial

Answer: (A)

When a higher-level office visit is paid at a lower level, the proper action is to appeal the payer with supporting documentation to show why the higher code was medically necessary. The appeal gives you the chance to review the medical record and demonstrate that the history, examination, and medical decision making meet the criteria for the higher level. Gather chart notes, exam findings, HPI/ROS, problem list, orders, and any relevant test results, then submit a concise summary with the original claim and payment details through the payer’s appeal process. This approach aims to recover the appropriate reimbursement by providing the payer with the detailed documentation they need to reconsider the determination. Avoid simply rebilling at the lower level, as that would not address the discrepancy and could raise compliance concerns. Asking the patient to adjust the charge or ignoring the denial also isn’t appropriate, since the payer’s decision affects payment and should be resolved through the proper dispute process.

When a higher-level office visit is paid at a lower level, the proper action is to appeal the payer with supporting documentation to show why the higher code was medically necessary. The appeal gives you the chance to review the medical record and demonstrate that the history, examination, and medical decision making meet the criteria for the higher level. Gather chart notes, exam findings, HPI/ROS, problem list, orders, and any relevant test results, then submit a concise summary with the original claim and payment details through the payer’s appeal process. This approach aims to recover the appropriate reimbursement by providing the payer with the detailed documentation they need to reconsider the determination.

Avoid simply rebilling at the lower level, as that would not address the discrepancy and could raise compliance concerns. Asking the patient to adjust the charge or ignoring the denial also isn’t appropriate, since the payer’s decision affects payment and should be resolved through the proper dispute process.