BCBS Downcoding Explanation 

Similar to Cigna claims, several individual BCBS licensees (e.g., Illinois, Texas, Massachusetts) have acknowledged that they will change (recoded/downcode) a claim to a lower‐payment code in certain situations, particularly for No Surprises Act (NSA) or Nonparticipating Provider claims.  

BCBS will assess level 4 and 5 E/M codes to determine if the level of service billed is appropriate for the severity of the member’s condition as reported on the claim. Consideration will include but will not be limited to: 

• Current claim information
• Member claim history
• For emergency department visits: information on the corresponding facility claim that may identify resources used as part of the visit (labs, radiology, pharmaceuticals, etc.)  

If an E/M code is determined to be overcoded, they may adjust reimbursement as follows: 

• Level 5 E/M code/reimbursement may be adjusted to level 4 or 3
• Level 4 E/M code/reimbursement may be adjusted to level 3.If you disagree with a determination, you may submit supporting documentation 

When they do this, they usually notify the provider on the claim summary and explain why the code was changed. They notify you when they do this on your provider claim summary.  

On NSA-eligible claims, they will provide: 

• Information when they change a code you submitted to a code associated with a lower Qualifying Payment Amount (QPA). The Final Rules refers to this as “downcoding” 
• An explanation of why they recoded and applied a different QPA 
• The QPA of the code you submitted and the one they paid. The NSA and related rules provide how the QPA is calculated, generally reflecting our median contracted rate for an item or service in the geographic area 

Please bill for E/M services in accordance with American Medical Association (AMA) and CMS guidelines.  

Blue Cross recognizes the 2021 and 2023 AMA code selection and reporting guidelines for E/M services which replace CMS 1995 and 1997 documentation guidelines.  

Blue Cross recognizes the 2023 AMA code selection and reporting guidelines for hospital inpatient or observation care services, consultation codes, emergency department services codes, nursing facility codes, and home or residence code services.  

Blue Cross recognizes the 2021 AMA code selection guidelines for outpatient office visit codes, 99202-99215. 

The NSA is part of the Consolidated Appropriations Act (CAA) of 2021 and the Transparency in Coverage Final Rule. 

Source: https://www.bcbsil.com/provider/standards/standard-requirements/caa/caa-downcoding 

https://provider.bluecrossma.com/ProviderHome/wcm/connect/780d8235-1555-439a-8bfc-c94eb22263f6/MPC_072125-2W-2-BG%2BEM%2Bovercoding%2Bprogram%2Bguidelines.pdf?MOD=AJPERES&utm