Glossary · Coding
Glossary · CodingDowncoding
A payer adjustment that reimburses a billed service at a lower complexity level than coded, typically when documentation is judged insufficient to support the higher level.
Definition
Downcoding.
A payer adjustment that reimburses a billed service at a lower complexity level than coded, typically when documentation is judged insufficient to support the higher level.
Sources
Primary references for this entry.
- CMS Medicare Claims Processing Manual.
- OIG Compliance Program Guidance for Physicians.
Related terms
Other terms in Coding.
- Coding
APC (Ambulatory Payment Classification)
The CMS payment grouping system used for hospital outpatient services under the Outpatient Prospective Payment System (OPPS). APCs bundle services into payment categories with relative weights.
Open entry - Coding
Bundling
Payer policy that combines multiple billed services into a single payment when one is considered an integral component of another. Often enforced through NCCI edits.
Open entry - Coding
CPT (Current Procedural Terminology)
The American Medical Association's standardized code set for medical, surgical, and diagnostic procedures. Five-digit numeric codes (with two-digit modifiers) used for professional billing on the CMS-1500 form.
Open entry - Coding
DRG (Diagnosis-Related Group)
The CMS payment grouping system for inpatient hospital services under the Inpatient Prospective Payment System (IPPS). Each DRG carries a relative weight that determines the lump-sum payment.
Open entry - Coding
E/M Coding (Evaluation and Management)
The CPT code family (99202-99499) for office visits, hospital visits, and consultations. Levels (e.g., 99213 vs 99214) are determined by complexity of medical decision-making or total time.
Open entry - Coding
HCPCS (Healthcare Common Procedure Coding System)
A CMS-maintained code set divided into Level I (CPT codes) and Level II (alphanumeric codes for products, supplies, and services not in CPT, including durable medical equipment and drugs).
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