If a level four office visit is paid as level three, which action should be taken?

If a level four office visit is paid as level three, which action should be taken?

• A. Submit an appeal to the carrier with supporting documentation
• B. Backdate the visit
• C. Cancel the claim
• D. Request a payer audit

Answer: (A)

When a higher-level office visit was paid at a lower level, the proper move is to file an appeal with supporting documentation to request payment for the higher level service. The level of an E/M code depends on documented history, exam, and medical decision making; if the chart shows enough complexity to justify a Level 4 visit but the payer reimbursed as Level 3, you should submit an appeal (reconsideration) and attach the encounter notes, findings, rationale, and any other documentation that supports the higher level. This gives the payer the information needed to re-evaluate the claim and adjust payment accordingly. Backdating the visit isn’t allowed, as dates must reflect what actually occurred. Cancelling the claim isn’t necessary since you’re seeking adjustment through an appeal. A payer audit isn’t the standard remedy for a single underpayment; use the appeal route with complete documentation to recover the appropriate payment.

When a higher-level office visit was paid at a lower level, the proper move is to file an appeal with supporting documentation to request payment for the higher level service. The level of an E/M code depends on documented history, exam, and medical decision making; if the chart shows enough complexity to justify a Level 4 visit but the payer reimbursed as Level 3, you should submit an appeal (reconsideration) and attach the encounter notes, findings, rationale, and any other documentation that supports the higher level. This gives the payer the information needed to re-evaluate the claim and adjust payment accordingly. Backdating the visit isn’t allowed, as dates must reflect what actually occurred. Cancelling the claim isn’t necessary since you’re seeking adjustment through an appeal. A payer audit isn’t the standard remedy for a single underpayment; use the appeal route with complete documentation to recover the appropriate payment.