Key takeaways from this episode

• Payer downcoding arrives as an EOB remark, not a denial, so it slips past auto-posting. Private payers are automatically paying level four and five E/M visits at 99213 or 99203 with a note that they "reviewed the chart and paid a different code"; train the RCM team to recognize each payer's remark code and route those claims to a dedicated work queue.
• A down code is overturned only by a formal appeal with records, not a corrected claim. Build a payer-by-payer protocol for assembling the note, submitting it, and following up, and have someone scan the documentation before it goes out, because appealing unsupported level fours only generates more denials.
• Getting off a payer's downcoding list takes a separate request backed by your overturn data. Contact the provider rep with proof that at least 70 percent, ideally 80 to 90 percent, of appeals were overturned; if the payer has no stated waiting period, start asking right away and repeat every two to four weeks, since removal is rarely automatic and can be reversed later.
• Payers run appealed records through computer-assisted coding tools, so a second appeal citing the specific E/M rules is sometimes needed. Documentation with a clear medical decision making trail usually clears the first review, but pattern-based software still gets some level fours and fives wrong.
• Addenda written after the down code may be ruled inadmissible. Payers have precedent for rejecting documentation added after a records request, so time statements and other supporting details must be in the original note, and appeals must include every part of the record, including time captured outside the baseline note by some EMRs.
• Always appeal, because payers watch who does not. Dr. Ray Painter warns that practices that let down codes stand are flagged as "not watching" and get downcoded more aggressively, a pattern PRS has seen since the early HMO days.
• Each unchallenged down code costs roughly $40 to $100 per visit. Physicians must know E/M medical decision making rules and verify what their templates and AI or EMR coding tools are producing, with the RCM team double-checking behind them.
• The Urology Advanced Coding and Reimbursement Seminar is January 30 and 31 in New Orleans. Registration and discounted hotel rooms are on the prsnetwork.com homepage, with Mark Painter, Dr. John Lin and Marianne Desciose presenting the 2026 changes.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 271, recorded January 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Downcoding: what payers are doing and how to catch it

[00:00] Scott Painter: On this episode: downcoding, the current scourge of reimbursement. Stay tuned. Welcome to episode 271 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Today we want to talk about downcoding. It's happening more and more, and we know it is adding administrative burden to your RCM staff and causing all sorts of problems. But if you don't pay attention to it, it's going to hit your bottom line and your top line. So, unfortunately, you have to pay attention to it and make sure it is at the forefront of your RCM and billing teams. Mark, do you want to share a little bit about what's going on and why it is so important?

[01:00] Mark Painter: We have addressed this a little in the past. As we've seen in the marketplace, many of the private payers have essentially implemented policies that randomly, or at least partially randomly, pay you a lower level for the E/M codes you bill. Typically, level fours and fives are paid out at 99213 or 99203. The processing of this in the EOB is not a denial, but typically a remark that says, we looked at your charts and paid a different code. So it's not an obvious denial, and it's not a request for medical records. It's just an automatic processing tool, and it has become a significant burden on practices and revenue cycle management teams around the country.

As you go through this, the first thing you have to get your RCM team tuned into is the appropriate remarks that come in from each of the payers, so you can get those denials flagged and popped into the right work queues, because if you're using automatic posting and you're not paying attention, those slide through. We've seen a number of practices that have not actually jumped on top of this. The second thing, unfortunately, with these particular denials, is that it's an appeal to get them overturned. So you've got to put together the information, submit the records back, follow up, and treat it as an appeal. It's not a corrected claim; it's an appeal. You're going to have to develop patterns and protocols within your practice to truly identify and respond.

The other thing you've really got to take care of is the process of documentation and follow-up. If you're submitting records that don't truly support a level four, and you billed a level four, you're going to see more denials, not fewer. But if your documentation is good and you can get that overturned with appropriate documentation, after a period of a few months with overturns of those down codes, you're going to be able to go back to the payer. It does take a separate effort of going back to the payer and requesting that you be removed from the downcoding queue. It's a separate issue; they're not going to automatically do it in most cases. Occasionally they will, but in most cases they're just going to keep flooding you with these down codes. So it does take that extra effort of contacting your provider rep, collecting the data on all the overturns, and demonstrating that you're above at least 70, but ideally 80 to 90 percent on your overturns.

This once again illustrates the circle of life, which is RCM. If you, as the physician, are not documenting appropriately in all that you do using the templates in the electronic medical record, or paying attention to whether your AI-assisted coding tools or EMR coding tools are actually interpreting what you're doing correctly, it's going to cost you additional money, for one thing, but also the time and labor to fight these downcoding issues as they occur. So gear up, roll up your sleeves, and make sure you're documenting appropriately. Pay attention to the E/M guidelines, to your templates and how they are used, and to what your automated coding tools are providing to you. When you look at this from an RCM protocol, you're really going to want to have somebody at least scan the records for appropriate documentation before you submit them, because, again, they're going to tell you they've reviewed your records, but they haven't. When you submit them back in, they're going to run them through a computer-assisted coding tool. So they are going to review your records and potentially deny them again, leaving you with yet a bigger problem. You don't want to appeal things that aren't supported. More importantly, as we've always said, you want to document what you do and charge what your documentation supports.

Guilty until proven innocent: why you must appeal

Scott: Questions, comments?

[07:00] Dr. Ray Painter: This is frustrating, because now you're guilty until proven innocent on your level of coding. Mark emphasized it, and I'd just like to re-emphasize: you've got to know that you've got a level four if you charge the level four, and you've got to know that it's well documented before you appeal it. And you definitely need to appeal, because if you don't, they probably now have software that tells them, hey, these folks are not even watching, so we're going to downcode a little more; we can save more money if we just don't pay them at all or pay them a lower number. So you've got to know you've got it right, you've got to know how to document, and you definitely need to appeal. We've seen this going on since the very beginning of the old HMO go-go days, where they watch practices, and if you're not minding the store, they will keep doing what they're doing.

Computer-assisted review and the addendum problem

[08:00] Scott: It's interesting, if you think about it. As Mark said, they're more and more sophisticated in reporting why they're not paying you what they should in their remarks, as opposed to a denial, so it slips through the auto-posting protocols. They're getting smarter in the way they do it, and forcing a lot more burden on the physician office. Question for you, Mark. In the appeals, obviously you've got to have the defensible documentation, but if you do have the correct documentation, does it usually take just one appeal to get that done? And is that done fairly quickly?

[09:00] Mark: For many of the cases, yes. When we've got good, solid documentation, it's apparent that most of these payers are handling the volume of appeals by using computer-assisted coding tools, which means you've got a computer reading through the record and a scorecard the computer is using to drive the initial results. They may have a few reviewers who really take a look at the findings for any adjustments, for flags that come up, but the computer-assisted coding tools are essentially following a pattern. Now, I'm not saying it's right in all those cases, and there are cases we've seen come back as incorrect where we've had to deal with a second appeal to point out, using the rules, exactly why a level four or a level five is supported.

The other thing that's at issue, as we've dealt with a number of these audits across the board, is addendums. As you look at your records, you need to make sure they're correct right out of the bat, because addendums are typically added after a request, after the denial or the down code has already been executed by the payer. That's an area where they've got a little bit of precedent to say that addendums added after the request are not admissible as additional documentation. So it does make it important to have that documentation in. We've had a few folks who have added time as a defensible level four for those few visits that fit that way, and sometimes that time recording within the record isn't in the initial note that's sent. That's the other piece: as you send those appeals, make sure you've got all of the information from all parts of the medical record included with that appeal. That's understanding your electronic medical record system. We've seen several different medical records where the timestamp you use doesn't actually get added to the baseline note, so you're having to add that information from a separate document in the medical record. I don't think that's as common as every record, but it is something you want to make sure of as you submit all the information. And again, you want to have all that documentation in ahead of time. Obviously, if you need to make an addendum, make it, but know that they may flag it as not admissible to support that particular code. I'm not saying don't addend your notes; if you forgot something, do that. But ideally you would make those addenda to your records before you get the down code.

When to ask to be removed from the downcoding queue

Scott: That makes a lot of sense. You gave a timeframe of roughly three months for when you request to be dropped from the automatic downcoding. Have you tried earlier, and what happens when you try early? Is three months the sweet spot you've found, or does it matter? Could you ask every week? How would you recommend they do that?

[13:00] Mark: Different payers have different policies with regard to how long you need to be overturning these down codes. If there's not an officially stated policy on when you can request removal from the downcoding list, then I'd start right away, especially if you're at 90 or 80 percent, or above 70. I'd try to drive everything up a little bit. As you go through this, you've got to, unfortunately, play this game as we always do, payer by payer. Watch your bulletins, watch the guidelines, watch the protocols they've put in place, and build your protocols on response based on what you learn about the payer as you go through it. You want to build education manuals and protocols per payer to define where your office is going to respond and how. And know that if you've survived one downcoding regime for a particular period of time, great, congratulations, now you're off the list. It doesn't guarantee they don't put you back on somewhere down the road. So keep that information in your knowledge treasure book and keep your protocols up and running, because it may happen again.

Scott: Would you ask to be off that list on a weekly basis, every other week, monthly, once you start?

Mark: Again, I develop those protocols based on the payer. I'm going to be asking based on my results fairly routinely. I don't know that I would do it weekly; maybe every other week at the most frequent. Monthly would probably be the typical target.

Whack-a-mole and the documentation rules

Scott: Okay. Ray, any other questions, comments?

Ray: No. Listening to all this, it just reminded me: what's that old game you used to play where one thing pops up and you knock it down and then you have to hit another one that keeps popping up? Guacamole or something like that. I like that name. Guacamole. I like guacamole.

Mark: Whack-a-mole.

[15:00] Ray: Okay. But anyway, it just reminded me that back in the old days we had a lot more trouble documenting what we do, and then it was a big chore to send in a claim and so forth. Now everything's automated. But now the problem is on the other side, because they keep thinking of other ways not to pay you and how to throw roadblocks. So one thing pops up as another one gets solved.

[16:00] Scott: Indeed. If you really look at what this is putting more and more pressure on, which we have been preaching for the last 30 or 35 years, documentation is so important, and documentation for reimbursement is extremely important. Knowing those rules, so that you can make sure you are including those magic words that you need for documentation for reimbursement throughout the clinical documentation, makes learning the rules of E/M coding that much more important today, even with AI-assisted documentation and ambient listening. You've got to know the rules so that you can do it correctly, document it correctly, and document it defensively.

The New Orleans seminar

Scott: All right, let's wrap this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. One thing I also wanted to bring up, as it's coming up in three weeks now, is the Urology Advanced Coding and Reimbursement Seminar in New Orleans on January 30th and 31st. This year there are a lot of rule changes and there's a lot going on in urology and urology practices. We really encourage you to come join us at that seminar and learn from the experts, like Mark, Dr. John Lin and Marianne Desciose, and we can share with you what's going on now and what's happening in 2026. One of the best parts of that seminar is learning from the other practices around the country and hearing the solutions they offer. This is something you don't get from webinars or podcasts or the other things we do to get information out. Those solutions are so valuable that it's worth the time and investment to attend one of these seminars, and it's better to do it at the beginning or end of the year, while everything's changing and new, to hear what's going on and what you need to prepare for.

So that's a big plug, but we really do believe in this. Year after year, and we've been doing this for over 20 years, probably actually over 25 years, the constant feedback we get from attendees is that this is one of the best seminars they've attended for their practice and for themselves. It really shows that you're not in this alone. There is a community out there, and you've got to learn from the collective genius. So we do encourage you to attend. If you go to prsnetwork.com, right there on the homepage is a seminar registration button that will give you all the information you need. There are discounted hotel rooms available. Please come join us in New Orleans; we'd love to have you there. The more attendees we have, the better the mix and communication from across the country. Any thoughts on the seminar, Mark, Ray?

[20:00] Mark: There are very few places where those of us who are really interested in coding, reimbursement and function get to hang out with our own kind, and this is one of those places. You can come down and speak the same language and really open up about everything that's going on, take some great ideas, and for at least a couple of days grab some new information and some solutions that are working in the marketplace today. And of course we have folks who attend year over year, because it's not that our questions change, it's the answers. It's crazy, but it's fun, and I would love to see everyone down there.

Scott: Yes, and we have a lot of great exhibitors down there as well. They add to the conversation when we're talking about reimbursement and technology and what's going on. It's a really unique experience, and we encourage you all to come join us.

Final thoughts

Scott: All right, let's get some final thoughts. Mark, final thoughts?

[21:00] Mark: A reiteration of everything we've talked about. Really, you need to understand medical decision making in E/M coding. You need to understand your tools and leverage your tools. You also need to make sure your revenue cycle management team is on board, double-checking and staying on top of this. It is a full team effort to get through this. When you think about how many office visits you do, and you think about $40 per visit, or $80 to $100 per visit, that's automatically taken off the table, that's a big add in the wrong direction. So you want to stay on top of this. Make sure you've got your documentation in place so you've got an easy response, and don't let these guys get away with it. Ray, final thoughts?

[22:00] Ray: The documentation we keep talking about is not that difficult to understand, what you need to say, and it doesn't take you that long to understand the difference between your clinical documentation and your coding and documentation for reimbursement. So spend a little time, learn what you need to know, and then you'll feel much better about your day-to-day activity.

Scott: All right. Well, that's all we have for today. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

Urology Advanced Coding and Reimbursement Seminar

Information and Registration

PRS Coding and Reimbursement Hub

Access the Hub

Free Kidney Stone Coding Calculator

Download Now

PRS Coding Courses

For Urologist

For APPs

For Coders, Billers, and Admins

PRS Billing and Other Services - Book a Call with Mark Painter or 
Marianne Desciose

Click Here to Get More Information and Request a Quote