One level down costs a median $37 per office visit and up to $77 per ED visit in published commercial rates. Since October 2025 the biggest payers run automated downcoding programs. Your own 835 remittance files already prove what it is costing you. Drop them in and see, free. Nothing uploads.
SVC*HC:99213:25*220*44**1*HC:99214~ CAS*CO*150*34~
Sources: Cigna reimbursement policy R49 and Cigna provider newsroom; AMA "Payer E/M downcoding programs: what you need to know"; Maryland Insurance Administration Consent Order MIA-2026-03-009; Indiana HEA 1271; MGMA Regulatory Burden Report, April 2026. Cigna has paused R49 application for certain California fully insured plans pending regulator review.
These are live medians from Reddenda's benchmark index of federal Transparency in Coverage filings: the median state-level difference between each E/M level and the level below it, across all 52 jurisdictions.
| Downcode pattern | Median loss per visit | Published rates behind it |
|---|---|---|
| 99214 paid as 99213Established office visit, the workhorse code | $37 | 170,449 |
| 99215 paid as 99214Established office visit, highest level | $53 | 168,914 |
| 99204 paid as 99203New patient office visit | $62 | 141,993 |
| 99205 paid as 99204New patient office visit, highest level | $50 | 139,251 |
| 99285 paid as 99284Emergency department, level 5 | $64 | 114,383 |
| 99284 paid as 99283Emergency department, level 4 | $77 | 111,953 |
| 99223 paid as 99222Initial hospital care | $58 | 123,399 |
| 99233 paid as 99232Subsequent hospital care | $42 | 132,077 |
Live medians of state-level median differences, Reddenda benchmark index of federal Transparency in Coverage machine-readable files, all 52 jurisdictions, computed July 2026. Medicare reference point: under the 2026 Medicare Physician Fee Schedule, a 99214 downcoded to 99213 forfeits $40.42 per visit at the national non-facility rate. Individual state and payer amounts vary; figures are market benchmarks, not any single contract. Documented reimbursement opportunity is modeled, not guaranteed.
Export the electronic remittances (835 / ERA) from your clearinghouse or PM system and drop them in. Parsing runs in your browser. Patient names, member IDs, claim numbers, and exact dates are stripped on your device, with a visible counter of everything that was stripped.
Three detection tiers, each labeled by its evidence: downcodes the remittance itself documents, reductions the payer signaled with its own adjustment codes, and lines paid at the lower level's market rate. The evidence tier is always visible.
Every flag is benchmarked against real published contracted rates in your state and ranked payer by payer. Documented and signaled flags can become a first-level appeal letter in one click, citing the remittance evidence and the right appeal framework for the plan type.
When a payer adjudicates a different code than you billed, the 835 standard provides for reporting your submitted code alongside the paid code (per X12 guidance, the SVC06 field). Billed 99214, paid 99213, in the payer's own file. This is the strongest tier: the evidence is theirs.
CARC 150: "Payer deems the information submitted does not support this level of service." CARC 186, RARC N22 and M85 likewise signal level-of-service changes and E/M review. The AMA's own downcoding guidance lists these exact codes as the tells.
The code was left unchanged, but the allowed amount sits within 6% of the next lower level's state market median while at least 12% below the billed level's median. Labeled a review candidate, never proof: verify these against your own fee schedule first. Thresholds and sample sizes are always disclosed.
Your 835 files are parsed on your device and never uploaded. Only two things ever leave the page: the state and CPT codes needed to fetch the market benchmark, and, if you click the AI features, de-identified aggregate figures. That is the whole list.
Downcode Radar's appeal letters cite the frameworks below, matched to the plan type. Every citation was verified against the primary source. Regulatory context, not legal advice.
You are paid on collections, so every silent downcode cuts your revenue too. Batch-drop a client's 835s, hand them a ranked downcode report their EHR cannot produce, and work the appeals from the on-device worklist export with claim numbers intact. Be the firm that caught what the last firm missed.
One biller, no time, and Cigna has been paying your 99214s at odd amounts since October 2025. Export one month of ERAs, drop them in, and see your number in about ten minutes. Free to scan, nothing uploads, no BAA conversation with anyone.
High E/M volume multiplies every per-visit loss, and multi-state books need per-state benchmarks. The radar benchmarks each line against its own state's published rates, all 52 jurisdictions, and rolls patterns up payer by payer for your next payer meeting.
We checked seven downcoding and underpayment products in July 2026. Several detect E/M downcoding well. Every one is enterprise, sold through a demo, and needs your claims data in their cloud. Here is the honest picture, side by side.
| What it takes to catch your downcodes | ★ YOU RUN ITDowncode RadarReddenda | MD ClarityRevFind | AnomalyManage | Rivet | WaystarAltitudeAI |
|---|---|---|---|---|---|
| Detects E/M downcoding | ✓ | ✓ | ✓ | ~variance | ~DRG level |
| Parsed on your device, no PHI upload | ✓ | ✗ | ✗ | ✗ | ✗ |
| Self-serve, no sales demo | ✓ | ✗ | ✗ | ✗ | ✗ |
| Free to start | ✓ | ✗ | ✗ | ✗ | ✗ |
| No integration or IT project | ✓ | ✗EDI / EHR | ✗ | ✗ | ✗ |
| No BAA, your records stay with you | ✓ | ✗ | ✗ | ✗ | ✗ |
| Benchmarked to published market rates | ✓public market | ~your contract | ~your contract | ~your contract | ~your contract |
| Flat fee tied to results, never a cut of recovery | ✓flat USD | ✗quoted | ✗quoted | ✗quoted | ✗quoted |
| One-click appeal letter | ✓ | ~recovery team | ✗ | ✗ | ✓in-suite |
| Runs across a whole book | ✓by call | ✓ | ✓ | ✓ | ✓ |
Compiled July 2026 from each vendor's public product and pricing pages (MD Clarity RevFind, Anomaly Manage, Rivet, Waystar AltitudeAI; Adonis and Experian Contract Manager were also reviewed and fit the same enterprise pattern). Partial marks reflect a narrower or differently scoped capability, not its absence; several of these tools detect downcoding well. "No BAA" and "no PHI upload" describe Downcode Radar's on-device architecture. Competitors ingest claims and remittance data through EDI or EHR integrations, so a business associate agreement applies. This compares publicly stated capabilities and is not an endorsement; details change, so verify against each vendor.
See one real finding free: your biggest downcode pattern and one documented reimbursement opportunity, benchmarked to your state, no PHI required. To unlock the full per-CPT, per-payer breakdown, one-click appeal letters, and your counteroffer, we walk your own data with you and price it on a short call.
Your structure depends on your NPIs, payer mix, and the opportunity in your own data, so we price it with you on a short call. Documented reimbursement opportunity is modeled, not guaranteed.
See one real finding free: scan a month of 835s on your device and get your biggest downcode pattern and one documented reimbursement opportunity, no PHI required. Then unlock the full per-CPT, per-payer breakdown and your counteroffer on a short call. Your structure depends on your NPIs, payer mix, and the opportunity in your own data, so we price it with you on the call.
Book your discovery call → Want to see it first? Scan a remittance free. Documented reimbursement opportunity is modeled, not guaranteed.