clinicians.build · interactive
The Invisible Denial
Prior auth is the denial everyone fights. Downcoding is the one nobody sees — a payer quietly pays you for a 99213 when you documented a 99214. Illinois just passed a law saying a human has to sign each one. Here's what one signature is worth, across 60 real Medicare geographies.
The gap, in one number
A 99214 knocked down to a 99213 erases $33.57 — every time
In CY2024, Medicare's national allowed amount was $117.36 for a moderate-complexity established-patient visit (99214) and $83.79 for the low-complexity one (99213). The downcode isn't a rejection you can appeal on sight — it's a $33.57 leak, one line at a time, on a visit you already worked and documented.
103.7M
99214 visits billed to Medicare, 2024
$33.57
allowed $ lost per downcode
$3.5B
at risk if 100% were downcoded
The explorer
60 geographies, one dot each
Horizontal: how often a place bills the moderate-complexity 99214 instead of the 99213 (its "coding intensity"). Vertical: what a single downcode costs there, in allowed dollars. Dot size is 99214 volume. It's tempting to read the right-hand states as "up-coders" a payer should target — so drag the minimum-volume floor and watch the tidy outliers turn out to be tiny territories with a few hundred visits.
Illinois (the law)
state / territory
below floor
—
allowed $ lost / yr at this downcode rate
The critical lens. A high 99214 rate is not proof of over-coding — it's mostly case mix. Older, sicker Medicare panels genuinely generate more moderate-complexity visits, and states with more specialists bill differently than primary-care-heavy ones. The Illinois law leans on exactly this: it bars payers from downcoding by diagnosis code or algorithm alone, and specifically prohibits targeting the doctors who see the most complex patients — the ones who should sit on the right side of this chart. Read a dot as "a payer's temptation," not "a provider's guilt."
Why a builder should care
The near-term product isn't "prevent downcoding." It's prove it.
Illinois now requires a "natural person" following current AMA CPT guidelines to make or review each downcode, gives physicians a 90-day dispute window, and bans blanket algorithmic knock-downs. That's a paper trail with statutory teeth in one state — and a template the other 49 can copy.
The RCM tool that wins here doesn't block the payer. It flags every downcoded line, attaches the CPT-guideline citation, and auto-drafts the 90-day dispute letter — turning an invisible $33.57 leak into a documented, contestable claim. Compliance feature today in Illinois; optionality in fifty.
⚠︎ AI-generated · not reviewed by a human · CMS figures are CY2024 Medicare fee-for-service allowed amounts (Part B carrier data), which understate total commercial exposure and exclude Medicare Advantage. The downcode-rate slider is a modeling assumption, not an observed rate. Verify against the linked sources before relying on it.