Preliminary results of CMA’s recent Workers’ Compensation survey indicate that worker’s comp carriers are downcoding a high percentage of claims. More than 200 CMA member physicians responded to the December, 2000 survey.

While state law prohibits carriers from unilaterally downcoding original procedure codes, 40 percent of physicians reported that carrier downcoding is widespread, and 30 percent said that carrier downcoding had resulted in a reduction in payment for at least half of the claims they had submitted.

State law requires carriers to provide physicians with both the carrier’s rationale for proposed code changes, and the codes that the carrier believes better describe the physician services being claimed. These requirements help educate physicians about proper coding practices, provide physicians with a basis to appeal the payer’s decision, and make it more difficult for payers to downcode without good cause.

The appeals process is clearly time consuming. In fact, 40 percent of respondents said they do not appeal claims. But the 28 percent of respondents who do said they receive additional payment for more than half of the claims they appeal.

The administrative director for the Workers Compensation program can, after notification, levy significant fines against insurers for failing to comply with the coding- change requirements.

For additional information about payment for treating physicians please click here to access CMA On-Call document #1929. Members can also order the document by phone at 800/592-4262. Information: CMA Reimbursement Hotline, 888/401-5911.