Every coder and biller has the expectation that once the documentation is analyzed, guidelines are followed, codes are assigned, and the claim is filed; the appropriate reimbursement will be received. However, it is estimated that approximately 10 – 15% of medical claims filed are denied. The reasons may vary, but in all cases, a revenue cycle team experienced in working denials will receive the claim for rework due to a denial. Denial reasons range from payer policy not being followed, demographic and insurance errors, documentation insufficiencies, coding errors, and billing process issues.
The problem with denials for every provider is the lack of timely reimbursement for services rendered. Let’s look at one type of denial: medical necessity. The implication in this type of denial is the physician ordered a service, it was performed and resulted, yet for some reason the diagnosis code(s) associated with the service failed to support the visit, test, or procedure. The medical necessity denial requires a review of the documentation, against the code(s) submitted, modifier(s) appended, compared to any associated local coverage determination (LCD) or national coverage determination (NCD).
A review of the documentation showed a patient with right forearm pain following a day of softball practice. The physician ordered a left two-view forearm x-ray. The radiology report resulted in a right two-view forearm x-ray with no fractures. Following the physician's order, the coder assigned right forearm pain as the diagnosis and CPT code for left forearm x-ray. The mismatch between the diagnosis laterality and CPT laterality yielded the denial. The denials coder communicated with the physician’s office to determine the appropriate laterality to be right made the correction to right forearm pain and right two view forearm x-ray and resubmitted the claim.
How can this type of denial be prevented?
1. Feedback to the physician regarding caution in laterality specificity when ordering
2. Feedback to the coder to communicate any laterality specificity discrepancies before coding to reduce rework and denials.
It is imperative that the denials team provides feedback to the providers and coders regarding frequent denials to prevent recurrence. The revenue cycle professionals require ongoing feedback and education with examples of denials. Monitoring and trending denials can identify areas of concern that can quickly be addressed at coding touch base meetings.
Closing the loop with feedback on denials, such as medical necessity denials, can reduce rework, increase timely reimbursement for services rendered, and prevent recurrence. Working with providers regarding documentation specificity, especially with laterality specificity, location specificity, and condition type specificity, can reduce unspecified denials.
Eclat Health Solutions has certified coders experienced in working all types of revenue cycle denials, including writing appeals for third-party denials.
References:
www.onpointmedicalsolutions.com
https://www.cms.gov/medicare-coverage-database/view/article.aspx
AAPC Thought Leadership Team Jan 16, 2024
