Payer advocacy

The Academy opposes reimbursement policies implemented by payers that reduce the Evaluation and Management (E/M) level (known as downcoding) payment when the E/M code is appropriately documented and reported. Carriers will review claims from providers who are identified as coding at a higher E/M level as compared to their specialty peers. Some carriers are using proprietary algorithms that may incorrectly link specific diagnoses to certain levels of E/M, triggering claim edits within their claim processing systems.

Notable payer advocacy updates

• Aetna Claim and Code Review Program: The AADA is in ongoing discussions about the Aetna program, and requested clarification of the appeals process and ‘opt-out’ criteria.

• Because of AADA’s advocacy, Elevance Health delayed the relaunch of the E/M Leveling Program, and Elevance suspended the program indefinitely. While the AADA asked for full repeal of the program, the carrier reintroduced it in late 2023 but with a lower impact on most physicians.

• UnitedHealthcare: The AADA continues to address concerns with the UnitedHealthcare “Smart” edit program.

Academy resources

The Academy has several resources to guide dermatology practices in appropriate documentation and coding as well as effectively appeal inappropriate downcoding. If you have coding questions, please submit to coding@aad.org. Contact privatepayer@aad.org to report payer issues or if you have questions.

• E/M coding tools: Choose between 2020 and 2021 E/M coding sets

• Successful documentation tips that withstand an audit

• Private payer appeal letter tool