65.008 Downcoding and Bundling of Claims


Downcoding and Bundling of Claims: The Texas Medical Association opposes (1) The practices of insurance companies and their agents unilaterally downcoding evaluation and management services and bundling Current Procedural Terminology (CPT) codes that were correctly reported with a modifier; (2) the use of software or other methodologies to determine payment and/or denial of a claim based solely on the CPT codes, ICD-10 codes, and modifiers submitted on a claim; (3) the use of billing, coding, and payment methods that do not adhere to CPT guidelines, rules, and conventions; and (4) the patient’s past medical claim history being used as a tool to deny or pay a claim. A patient’s medical claim history is not an accurate or complete reflection of the patient’s overall health and should not be used as a substitute for a medical record. TMA will take all necessary and appropriate steps to stop these unreasonable business practices (Amended Res. 404-I-98; reaffirmed CSE Rep. 1-A-08; reaffirmed CSE Rep. 1-A-18; amended CSE Rep. 1-A-19).

Last Updated On

June 11, 2019