General Surgery Coding Alert

Here’s Part 2 in a series on filing appeals successfully.

In August, we reviewed the steps any good appeals “detective” would take in order to prepare the most solid appeal case possible: deciphering your explanation of benefits (EOB), knowing both Medicare and private payer policies, and backing your appeal with credible sources.

This month, it’s time to take your case to the payer. Follow this advice on creating an appeal letter that is beyond convincing, and best practices for following up with the payer after sending the appeal in.

Draft a Direct and Data-Driven Appeal Letter

This is where your preparation culminates. Your appeal letter must be precise, detailed, and leave no room for unclear explanations. Your appeal letter is like a powerful closing statement to a court, and it should be designed to overturn the denial.

Start your letter by clearly listing essential patient information at the top: Patient Name, Date of Birth (DOB), Member ID number, and the internal control number (ICN)/claim number.

Then, state the denied CPT^® code and directly explain why you dispute it. Avoid vague statements like, “We are disputing this denial; please reconsider.” Instead, be specific and data-driven.

Example: You might write: “CPT^® code [XXXXX] was incorrectly denied as ‘not medically necessary’ (Remark code CO50). According to [Payer Name] guidelines [policy name and/or number here], this service is medically necessary when performed for the clinical indications documented in [patient’s diagnosis] and documented findings of [specific findings from medical record].” This direct, evidence-based approach eliminates guesswork, presenting your case with absolute clarity.

Annotate Your Medical Record

The medical record is your primary witness, your undisputed evidence. Guide the payer directly to the supporting evidence, making it impossible to miss crucial details. Annotate your medical record to point out specifically where and how this service is supported.

• Underline the supporting section. Do not use a highlighter, as scanning can make it illegible. Underlining is visible.
• Use text boxes with arrows. Insert small text boxes next to underlined sections. Use arrows to tangibly show payers the exact location of support. Text within should briefly explain relevance (e.g., “Physician's detailed findings supporting [CPT^® code] are noted here”).

You are not just presenting evidence; you are leading them straight to the smoking gun, leaving no room for misinterpretation.

Example: For a denial based on lack of documentation/not supported, you’ve printed the relevant clinical note. Now, underline the paragraph detailing the physician’s specific findings and patient symptoms, directly supporting the service. Next to it, add a small, clear text box with an arrow pointing to the underlined text, stating: “Physician’s detailed findings supporting [CPT^® code] are noted here.” This leaves no room for oversight.

Submit Securely and Follow Up Diligently

Your battle continues until reimbursement is in your account. Proper submission and diligent follow-up are critical, ensuring your judgment is enforced.

The most secure and efficient submission method is via a payer portal, providing an immediate tracking number. This avoids claims of nonreceipt.

In your appeal’s conclusion, concisely recap the denial and dispute reason. Request a review of all attached sources and reconsideration for reimbursement. Importantly, ask for an explanation and clarification of the payer’s guidelines in response — demanding accountability and providing insights for future claims.

Example: You’ve uploaded your complete appeal packet to the payer’s secure online portal, receiving a confirmation number. You then calendar a follow-up call for two weeks out, preparing to escalate if the initial reconsideration is denied or unsatisfactory. You’re actively pursuing reimbursement justice.

Don’t let incorrect denials cost your practice. By mastering these steps — from deciphering the EOB like a seasoned detective, understanding payer policies as if they were legal statutes, meticulously building your case with credible sources, and crafting a precise appeal letter that stands as an ironclad argument — you can significantly increase your success rate and optimize your revenue cycle. Take control of your reimbursements and ensure your practice receives the payment it deserves for the vital services you provide.

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