Coding Corner:
Steps to Address Downcoding and Strengthen
Your Appeal Process
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Downcoding increases administrative burden and costs for practices. Please appeal to the payer if your documentation supports the originally billed code. To improve your chances of a successful appeal:
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Identify denials promptly and outline the Cigna and Aetna appeal process for your billing team. Aetna accepts appeals via Availity; Cigna accepts appeals via CignaforHCP.com.
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Review Medical Decision Making for complexity, data reviewed, and risk factors.
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Verify time-based coding includes all face-to-face and non-face-to-face care on the service date.
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Match documentation to CPT requirements; quality matters more than quantity.
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Check diagnosis code order; list ICD-10 codes by highest clinical significance.
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Update EHR templates to support accurate documentation.
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If an appeal is denied, request the payer’s reason for upholding downcoding. This information is vital for advocacy efforts.
After five or more successful appeals claims from Cigna, you can
make a request to have your claims bypassed from the policy.
Email:
EMCodingAccuracy@cignahealth.com
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Source: Revenue Cycle Innovations, LLC
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Regulatory Reminders:
Safe Storage of Medications
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Medication storage safety is essential to protect patients, reduce medication errors, and maintain compliance with regulatory standards. Here are some recommendations to consider when storing medications:
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Expiration Dates: Check regularly and rotate stock to minimize waste.
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Multiuse Vials: Clearly label with open date, expiration date (per instructions), and staff initials.
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Temperature Monitoring: Use calibrated thermometers and monitoring systems for refrigerated/frozen meds. Document checks and consider 24/7 electronic alerts. A temperature log template can be found at Immunize.org.
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Security: Keep medications secured, especially in pediatric areas. Separate look-alike/sound-alike drugs.
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Samples: Manage these with the same standards as other medications.
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Policy Review: Ensure documentation covers expiration, storage, and recall actions.
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Improvement: Invite a South Piedmont AHEC Practice Support Coach for an onsite review.
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Make it Happen: Update policies and staff training. Create or revise a checklist for medication room safety.
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NC Medicaid Provider Rate Update (Dec. 10, 2025)
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NC Medicaid Bulletin can be found here
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“Thank you for your continued commitment to the people of North Carolina. We know the provider rate reductions implemented in October created real challenges for you, your staff, and the individuals you serve. Those reductions were necessary to keep the Medicaid program solvent in the absence of adequate funding from the General Assembly.
Recent court rulings now require NCDHHS to reverse those reductions and restore rates to their September 30, 2025 levels. While this change brings short-term relief, it is important to be clear: the underlying financial crisis has not been resolved.
Medicaid is currently underfunded by $319 million. With the rate reductions no longer an available tool at this time, NCDHHS now has no remaining mechanisms to responsibly manage this funding gap. As a result, the Medicaid program is projected to run out of money early next year.
If this happens, the consequences will be far more severe than the rate change. The stability of the entire Medicaid program – and the care provided to more than three million North Carolinians – is at risk.
We want to ensure you have a clear understanding of the situation:
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The restoration of rates does not mean the problem has been resolved.
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The financial risk to Medicaid is greater now than before.
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Decisions about future funding are solely in the hands of the General Assembly.
We will continue to communicate transparently as the situation evolves and keep you informed of any developments that may affect the people you serve. We remain deeply grateful for your partnership and dedication during this time of significant uncertainty.”
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Medicaid Rate Reduction Update
Reversal Update (Dec. 19, 2025)
“Effective Dec. 10, 2025, the State announced the reversal of Medicaid reimbursement rate reductions that took effect Oct. 1, 2025. These reductions, generally between 3% and 10%, impacted doctors, hospitals and other medical providers statewide. The State is now taking immediate action to update NC Medicaid Direct) fee schedules to align with rates in effect Sept. 30, 2025.
This includes updating the November and December NC Medicaid Direct fee schedules that were posted on Oct. 1, 2025, which implemented the reduced rates effective Oct. 1, 2025. The updated NC Medicaid Direct fee schedules are targeted to be posted on the Department’s Fee Schedules and Covered Codes Portal by Jan. 5, 2026. NC Medicaid annual procedure code updates will also be reflected in updated NC Medicaid Direct fee schedules posted Jan. 5, 2026."
Full details can be found in the NC Medicaid bulletin
here.
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NC Medicaid to Reinstitute Coverage of GLP-1s
for Weight Management (Dec. 19, 2025)
“In accordance with the Governor’s directive
, NC Medicaid coverage for GLP-1s for the treatment of obesity is being reinstated effective Dec. 12, 2025.
Coverage of GLP-1s for Weight Management will revert to the criteria in place as of Sept. 30, 2025, restoring access to medications previously available under the NC Medicaid Outpatient Pharmacy Prior Approval Criteria GLP-1s for Weight Management, effective Aug. 1, 2024.
Providers should consider whether members have experienced a lapse in treatment, change in therapy and whether a lower starting dose is necessary."
Full details can be found in the NC Medicaid bulletin
here.
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2026 Federal Provider Enrollment
Application Fee Increase
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Initial enrollment;
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Re-enrollment;
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Adding a new owner or a new site location; and
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Re-verification.
NCTracks provides a record of federal fees and NC Enrollment fees by year so providers may note the updates. The Federal Fees & NC Enrollment Fees by Year spreadsheet can be found under Quick Links on the Provider Enrollment page
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Additional information regarding the federal fee can be found on the public-facing NCTracks provider portal
Federal Fee and NC Application Fee FAQs page.”
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Medicaid Managed Care Webinars
and Training Courses
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There are many opportunities to stay on top of Medicaid Managed Care and Health Plan changes. The NC DHHS website contains a resource page for the Provider Playbook Training Courses. This includes Provider Virtual Office Hours, Managed Care Webinars, Back Porch Chats and Updates to the Standard Plans, Tailored Plans and Children and Families Specialty Plan. You can find the link here for a list of future training and archived meeting materials.
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NC DHHS’s Managed Care Claims Monitoring Dashboard has a new tab titled Managed Care Payment Outcome Summary. According to the site, the “data is sourced from the EPS but includes only the latest payment outcome for services captured across multiple claims submissions. The Payment Outcome Summary data identifies claims with the same values for key fields based on the Claim Type and determines the payment outcome accounting for all claim iterations.”
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Accessing Clinical Criteria
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Partnering with Parents: A Collaborative Framework
for Supporting Parent Involvement in Clinical Work
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Support and buy-in from parents and caregivers is integral in the well-being and outcomes of children and adolescents. This training will aid healthcare professionals in fostering strong relationships with parents and caregivers. Various training topics will be explored. This is a live webinar that will be held on March 14, 2026, from 11:00 AM to 1:00 PM. Registration and additional information can be found here on the South Piedmont AHEC website.
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