Essential Tips for Successful Appeals

Essential Tips for Successful Appeals

Successful appeals are often a result of how you present appeals to your carrier. Here are vital tips to achieve successful appeals.

Be Prepared: Anyone speaking with the carrier regarding an appeal—be it a coder, biller, office manager, or provider—should have the knowledge and detailed information necessary to discuss that appeal. The individual should be able to review the operative note with the payer, to explain the rationale for the coding/billing, and to demonstrate why the claim should have been treated differently.

Write an Appeal Letter: Don’t just send an explanation of benefits (EOB) with a balance bill. Instead, spell out for the payer exactly whatyou wish them to review (such as fees, coding denials, etc.). You’ll have to spend a few extra minutes to put your request in writing, but it can make a big difference.

Correct the Claim Before You Appeal: If the original claim was incorrect, appealing with the same claim will not change your results. Double-check the claim’s EOB, CPT® coding, diagnoses, and the documentation to be sure it is correct. Be absolutely certain you are applying modifiers appropriately. Adding modifiers to a claim just to get it paid may lead to accusations of fraud or abuse.When you’ve finished reviewing the claim, make the necessary changes and/or documentation addenda before resubmitting.

Code Only What Documentation Supports: The golden rule of coding is, “If it isn’t documented, you can’t report it.” If you are billing a surgery, review the body of the operative note to be sure that all the procedures reported actually were performed. A common mistake is to code from the “list of procedures performed” at the beginning of the operative note. As payers and auditors know, these lists often do not accurately reflect what occurred in the operating room. A careful reading of the operative note might even reveal separately reportable procedures that would have been missed if relying only on the note summary.

Similarly, coders shouldn’t rely on a physician’s recommended coding, but should instead review the documentation to be sure they are reporting the correct codes. If necessary, the physician should be prepared to amend the record to better reflect the nature of the service and/or the patient’s condition.

Avoid “Simple” Mistakes: Many denials are the result of obvious errors, such as missed timely filing deadlines; illegible claims; claims not properly filled out (e.g., incorrect patient identifier info.); failure to obtain pre-authorization; and wrong, insufficient, or non-existent documentation. These errors can be avoided easily by double-checking claims prior to submission. It’s worth the time: You’ll receive payment quicker, and the payer does not have to process a denial EOB for an avoidable error.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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