Solve the Case of the Unnecessary Claims Denial
Be on the lookout for clues to submit a successful appeal.
Denials and appeals can be the most frustrating parts of a coder’s job. I have been on both sides of the fence — working pro-fee for a healthcare system, handling denials, and working for a payer, looking at denials. In my experience, there are several things you can do, easily, to get claims paid without delay.
Look for a Motive
A man saw his wife making a roast. Before she put it in the oven, she cut an inch off one end. When the man asked his wife why she did this, she replied, “That’s the way my mother did it.” The man later questioned his mother-in-law, and she answered, “That’s the way my mother did it.” When the man asked Grandma about it, she said, “I didn’t have a pan big enough to fit a whole roast.”
Just because something has always been done a certain way doesn’t mean it’s correct under the present circumstances. When it comes to quality improvement in healthcare, the phrase, “We’ve always done it that way,” is often a clue that something is being done in a less-than-optimal way.
Claim remittances come back with codes to explain a denial. Use these codes as clues to submitting a successful appeal. Not understanding remittance codes, or not addressing what the codes convey, assures the claim will be denied once again.
State Your Case
“Coding correct” is the most used (and problematic) return a payer can get. Most payers automatically run claims through a computer program to check the coding. The computer program logic has been tested and researched, so if it flags a coding error, it’s probably a coding error. Writing “coding correct” on a denied claim doesn’t explain to the payer why you think your coding is correct.
“Does not bundle” is another common way denials are mismanaged. Again, that computer logic has detected a bundling error. Many times, it’s as simple as a missing modifier 25 Significant, separately identifiable evaluation and management service by the same physician or qualified healthcare provider on the same day of the procedure or other service to override the system edit that bundles evaluation and management (E/M) services with procedures performed on the same day by the same provider.
To avoid bundling issues, check the National Correct Coding Initiative (NCCI) table and the procedure-to-procedure (PTP) edits before submitting the claim. The NCCI table is on the CMS.gov website under the Medicare tab with the heading “Coding.”
When a provider has performed two or more services during an encounter, and documented not only the need for those services, but how they are separate from each other, a modifier should be used to unbundle those procedures. The appropriate modifier depends on what was done. This could be a procedure on different areas of the body or a procedure performed by another provider.
Column F of the NCCI table tells you if a modifier is allowed, and which code is primary. Not all codes need a modifier, but if the documentation supports a modifier, don’t forget that it always goes on the secondary code.
All the codes in a claim count: A code that is primary to another code may, itself, be secondary to still another code (and therefore may need a modifier). For example, a dermatologist may provide several services during one encounter:
- Simple incision and drainage (10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single);
- Removal of skin tags (11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions); and
- Benign lesion excision on the neck (11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less).
In this case, although 11420 would be primary to 10060, 11200 is primary when combined with either of those codes. To prevent a line item edit, modifier 59 Distinct procedural service must be put into play. This is then billed as: 11200, 11420-59, 10060-59.
Reporting services within global period, reporting multiple E/M visits the same day, and reporting an E/M on the same day as a procedure are other common circumstances when modifiers are necessary, but either forgotten or misapplied.
Remember: Modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period indicates an office visit is not related to a surgery in a global period, whereas modifier 25 indicates that an office visit is a significant, separately identifiable service from the procedure. If, during a global period for a surgery, a patient is seen by the physician who performed the surgery for a different illness, and a procedure is performed, the E/M code would need both modifiers 24 and 25.
Consider the Circumstances
When it comes to diagnosis and procedure codes, patient age is important. Preventive medicine coding can be tricky, especially when it comes to the pediatric population. Newborn health is separated by the first eight days, eight to 28 days, and 28 to one year for diagnosis codes; but CPT® coding is the same for all infants (less than one year of age). Childhood is grouped into early, late, and adolescent.
For example, preventive medicine visits are divided into age groups, and the pediatric and adolescent groups are broken down even further. A preventive medicine visit for a 10-year-old is reported 99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years); whereas the same visit for a 12-year-old is reported 99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years).
Regarding diagnoses, for instance, a newborn patient with respiratory distress syndrome (P22.0 Respiratory distress syndrome of newborn) would have a different diagnosis than a child or adult (J80 Acute respiratory distress syndrome).
Body mass index diagnosis codes follow an entirely different set of rules, and a patient is not considered for adult diagnosis until they are 21 years old.
Don’t Compromise Patient Privacy
Many coders are guilty of the “when all else fails, send the notes” mentality. But we should remember: Our patients’ privacy is of the utmost importance. Sending doctors’ notes not only puts our patients’ protected health information at risk, but it also won’t help to get claims paid. The payer is not coding or auditing the encounter notes, and without any idea of what to look for, the chances of that claim getting the denial lifted are rare.
A little information goes a long way towards effectively submitting a denial; telling the claims examiners where to look, and why, will ensure timely and correct processing of the claims. Let’s keep our patient information to the minimum necessary, while doing our best to process those claims.
Bethanne Wilkie, CPC, CRC, EMT, CNA, is a senior coding specialist with 20 years of experience in both the clinical and business aspects of healthcare. She is a member of the Madison, Wis., local chapter.
NCCI edits: www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html
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