Medicare Compliance & Reimbursement

Tip: Don’t forget about NCCI edits.

One of the benefits of being a Medicare provider is that you are allowed to appeal claims decisions you disagree with. However, if you lose more appeals than you win, you may be missing some key steps. Brush up on some of the basics to bolster your success rate.

That was the word from Jazz Harrison, senior provider education consultant with Part B Medicare Administrative Contractor (MAC) Palmetto GBA, during the payer’s presentation, “Why Deny?”

Consider adding these five steps to your Medicare Part B appeals wheelhouse to boost your claims success rate.

Step 1: Check a Few Key Details Before You Submit

Although most coders are usually diligent about knowing which ICD-10-CM codes to submit to payers, sometimes important diagnosis coding details can slip through the cracks, leading to denials that require you to appeal.

If you’d like to reduce the number of claims that are on your appeal list, taking this step — among several others — can help tremendously, Harrison said. “Prior to submitting a claim for a service that has a utilization or a frequency limit, review previous claim submission and dates and refer to the applicable LCD or NCD policies,” she said. In addition, check for National Correct Coding Initiative (NCCI) edits, medically unlikely edits, whether the patient is in a global period of a surgery, and that you have the appropriate diagnosis codes on the claim, she advised.

“You can often avoid having to submit an appeal if you make sure that the required diagnosis code or codes are present on the claims you submit,” pointed out Swandra Miller, senior provider relations representative with Palmetto, during the event. “Some services must be billed with both a primary and a secondary diagnosis to be covered by Medicare, so it’s important that you look to see if the secondary diagnosis is included on the claim,” she explained.

Step 2: Investigate Whether Medicare Is Primary

Some denials are due to Medicare Secondary Payer (MSP) issues, so always check to make sure Medicare is the primary payer before you submit your claims. This is another step that could help you cut down on denials later.

“MSP provisions prevent Medicare from paying for items and services when other health insurance coverage is primary,” Miller said. “When Medicare is secondary, the primary payer must pay first.”

Before submitting a claim, verify whether Medicare is a primary or secondary insurance for the patient, and that way you’ll know which insurer will pay first and which should receive the claim second.

Step 3: Know Why You’re Appealing

Don’t allow yourself to have a knee-jerk reaction to a denial in which you send off an appeal asking the payer to reconsider payment before really scrutinizing the reasons for denial. Instead, take a methodical approach once you understand exactly why your claim was denied, and therefore why you’re appealing.

“Read the remittance advice before you submit an appeal,” Miller cautioned. “Make sure that you know why the claim was denied before submitting your appeal request. It’s difficult to provide favorable appeal decisions when the provider thinks they’re appealing a duplicate denial, when the service actually denied due to excessive frequency. The documentation you submit needs to address the reason that the service was denied.”

Step 4: Clarify What You’re Appealing in Overpayment Requests

If a payer indicates that you were overpaid and requests money back, you may not always agree — but you have a right to appeal that. If you do pursue this route, always include a copy of the overpayment letter with your overpayment appeal, Miller reminded.

“If there are multiple claims included in the overpayment letter, please make it clear which claims you’re appealing,” she noted. “If you’re appealing all of the claims of an overpayment letter, say so in your appeal request. The appeals department must be able to identify all of the overpayments being appealed to stop collection activities on those receivables.”

Step 5: Prepare for Documentation Requests for Code Changes

In some cases, you may believe you submitted the wrong code, and that in actuality your records represented a higher-level code than what you initially reported. In these cases, you should submit documentation to support your claim, Miller recommended.

“If you requested the appeals department to change a lower-level code to higher-level code, like going from 99213 to 99214, please attach the medical records,” she said. “Upcoding requests are handled as appeals, even when they’re sent with the reopening request form. They are subject to the appeals time limits, and must be reviewed to determine if the higher-level code is appropriate.”

In addition, don’t forget to change the billed amount on an upcode request, Miller added. “If you’re asking to change the HCPCS code to one that has a higher allowed amount, don’t forget to request that the billed amount also be changed. The appeals department will not change the billed amount, unless they are specifically asked to do so.”