Internal Medicine Coding Alert

Published on Thu Oct 01, 1998 PDF

Appealing denied or downcoded claims is one of an internal medicine practices biggest headaches. When you consider the time it takes to go over the evaluation of benefits (EOB) to see where the payer disagrees with the charge, the time spent preparing and re-submitting the claim, and the requisite six-week (or more) wait for payment, the money recouped is often not enough to cover the practices cost to appeal.

But, in many states, Medicare carriers have instituted special telephone-review lineshot lines that allow practice coders to call in minor changes to a claim. For example, on these lines you can often correct a diagnosis code, add a modifier, or change an E/M code.

In most cases, the changes go right into the payers system and the payment is made to the practice in the same cycle, not several weeks later, as with regular paper appeals.

Everything we can get in on the telephone reviews, we certainly are doing it, says Teresa Burnett, CPC, reimbursement specialist with the Clark-Holder Clinic, P.A., in LaGrange, GA. You call it in that week and you usually get your money the next. It is certainly well worth your time. We are almost 50% Medicare, and we try to save everywhere we can.

Burnett has been surprised at the number of practices that dont use the service, she says. People tell me they didnt even know it was available.

Practice managers and coders should check with their state Medicare carrier if they are unsure of whether it has a dedicated telephone review line.

How to Use Telephone Review

While the specific requirements for re-submitting claims over the telephone vary from carrier to carrier, most of the basic elements are the same.

1. Use only for minor changes. In most cases, practices use telephone reviews to correct minor mistakes to a claim.

Sometimes we have a diagnosis code that wasnt changed from the previous visit, or if we didnt submit all of the diagnosis codes, or didnt put one as primary, thats what we usually end up changing, says Nancy Asher, the billing and collections supervisor for Doctors on Duty, a free-standing ambulatory care clinic in Union, NJ.

If the problem is more complicated, like use of a modifier that requires the practice to append documentation notes, then the claim must be submitted in written form, says Burnett.

2. Some restrictions apply. The Georgia Part B telephone review line doesnt allow appeals requiring a change in the year of service or appeals with Medicare Secondary Payer denials stating that the patient has other insurance, Burnett notes.

However, it does allow appeals that require a change in the month or day of service, those that were denied due to a missing UPIN number, or those requiring a change in the number of services.

Note: Be sure to inquire about this information with your carrier. For example, Nationwide Medicare Operations, the Medicare Part B carrier for West Virginia and Ohio, does not accept telephone reviews of claims processed more than six months prior to the call, potential or requested overpayments, or claims denied as unprocessable (e.g., missing a UPIN number, date of x-ray, or place of service.). Their telephone review guidelines are published on their web site (http://www.nationwide-medicare.com).

3. Only three claims per call. Most of the review lines surveyed by IMCA allowed a maximum of three claims appeals per phone call. But, both Burnett and Asher say that operators on their lines have allowed them to submit more if the phone traffic was slow.

Sometimes, if theyre not really busy, theyll say, You know, its kind of slow today, what else have you got? Burnett says. Ill say, Ive got 10 more. They may say, Go ahead and give them to me.

4. Have basic information ready. The New Jersey review line only requires the providers name and claim number and the information that should be changed to process the appeal, says Asher.

In Ohio and West Virginia, however, practices must give the callers full name, the provider identification number, the beneficiarys Medicare number, the date and type of service, the billed amount, and the reason for the review.