Revenue Cycle Insider

Do you know what EOB remark codes are?

Every medical practice has faced a claim denial, costing crucial revenue. Denials are a frustrating reality in revenue cycle management.

But what if you could transform these rejections into reimbursements? This guide offers a clear, guided roadmap to crafting appeals that payers can’t ignore, helping you reclaim what’s rightfully yours.

Approach appeals first as a documentation detective uncovering critical clues, and then as a seasoned lawyer building an irrefutable case. If you can fill both roles successfully, your appeal will stand a stronger chance of acceptance.

Decoding EOB Is Your First Clue

When a claim is denied, your explanation of benefits (EOB) is more than just a document; it’s your initial crime scene, your most vital piece of intelligence. You must pinpoint the exact reason for the denial, meticulously examining every detail like a detective.

Uncovering the ‘Why’ Behind Every Denial: The Case File Begins

The EOB provides the precise denial code and reason, which is crucial for a strong appeal. Without this, your strategy is baseless. Common denial reasons include:

• Bundled/inclusive (Remark code CO97): The payer believes the billed service is part of another procedure performed concurrently and not separately reimbursable.
• Not medically necessary (Remark code CO50): The payer disputes the clinical need for the service.

Uncovering the specific denial reason is the fundamental first step. This clarity dictates your entire strategy.

Example: Your claim for CPT^® code 29823 (Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])) was denied as bundled. The EOB specifies the payer believes this service should not be billed separately from another procedure during the same encounter.

This immediately guides your next steps: checking unbundling rules and payer coding policies. You’ve pinpointed the exact charge, like a lawyer identifying a key point of the dispute.

Know Your Opponent: Payer Policies Are Paramount

You cannot win without knowing the rules. Many private payers have unique guidelines, and assuming they all follow Medicare can lead to persistent denials. Your role is to uncover their specific “laws,” or private policies.

Research Payer-Specific Policies: Cracking Their Codes

Before drafting your appeal, investigate the specific payer’s policies for the denied service. Does it strictly adhere to Medicare guidelines, or does it have its own private policies? This information is typically found on the payer’s website in a “Provider” or “Medical Policy” section or verified via a call to provider services.

Determining specific payer guidelines is critical to effectively disputing the denial, directing you to the most credible sources of support — much like a lawyer researching legal statutes. Always confirm the payer’s appeal submission timeline to ensure you’re within the window; missing this deadline is like missing your court date.

Example: Your claim for a particular injection was denied as experimental/investigational (Remark code CO55). A check of the payer’s website reveals a specific medical policy outlining criteria for this injection. You discover their policy requires diagnostic results or prior authorization that was not initially submitted. This information is a game-changer, telling you exactly what documentation to gather. You’ve found the missing evidence your appeal defense needs.

Arm Yourself With Evidence: Building an Irrefutable Case

A strong appeal is about proving your case with accurate and credible evidence, like a prosecutor presenting a rock-solid argument. Without supporting documentation, your appeal is an unsubstantiated claim.

Gather Credible Sources to Back Your Claim: Presenting Your Exhibits

Bolster your appeal with relevant and credible documentation. These are your expert witnesses, providing undeniable proof. Invaluable sources include:

• Centers for Medicare & Medicaid Services (CMS) policy: Use this as your main resource for Medicare claims, or for private payers following Medicare guidelines.

• AMA CPT^® Assistant articles: The journal offers official interpretations and coding guidelines for CPT^® codes.

• Specialty-specific guidelines (e.g., American Academy of Orthopaedic Surgeons [AAOS]): Check out these clinical guidelines and best practices for supporting medical necessity.

• Peer-reviewed medical literature: Use this resource for complex medical necessity arguments.

Carefully review these sources to confirm they do not conflict, as inconsistencies weaken your argument. Save these guidelines, articles, and policies to attach to your appeal packet. It is critical to directly quote pertinent sections in your appeal letter, making them your star witnesses speaking directly to the reviewer.

Example: CPT^® code 29823 was incorrectly denied as bundled into 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair). You find a December 2020 CPT^® Assistant article (Volume 30, Issue 12) explicitly stating that 29823 is appropriately billed separately when the debridement is documented in three discrete structures separate from the rotator cuff repair. Your clinical note confirms debridement of the labrum, glenoid bone, and humeral bone. Further, if the payer follows Medicare and National Correct Coding Initiative (NCCI) edits, an additional strong resource supporting separate reporting of 29823 is Chapter 4.7 of the NCCI Policy Manual. These are the powerful documents you'll quote and attach, providing concrete, undeniable proof.

Next month, we’ll take a look at the final steps you’ll need to take to lock up your appeal.

Valerie Ramirez, CPC, CPMA, CRC, COSC, Coding Integrity Specialist,
United Musculoskeletal Partners