Denied Services:
Follow Three Key Steps to Successfully Appeal Denials
Published on Wed Sep 01, 1999
Denials for services ethically claimed are an irritating and fairly frequent occurrence for otolaryngology practices. Even more annoying, however, are denials when the claims were correct. Fortunately, the otolaryngologist is not without resources when incorrect denials occur.
The appeals process can be frustrating, time-consuming and can yield relatively little. Still, it offers a way for ENTs to make their case and gain reimbursement for procedures that were inappropriately denied.
Step 1: Compare What You Charged
With What You Receive
One reason procedures may not be reimbursed is inappropriate bundling by payers. Even if all National Correct Coding Initiative (NCCI) edits were checked before the claim was made, some carriers tend to bundle a wide range of procedures, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ, whose clients include otolaryngology practices.
She notes that many carriers will inappropriately rebundle endoscopic sinus procedures and turbinates. Meanwhile, endoscopic ethmoids, maxillaries and sphenoids may be rebundled into the sphenoidotomy.
For example, if you performed an ethmoidectomy (31254, nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]), a 31267 (nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) and a sphenoidotomy (31287, nasal/sinus endoscopy, surgical, with sphenoidotomy), I would expect managed care carriers, at a minimum, to allow about $1,800-$2,000. Therefore, if their allowable is only in the $900 range, you know they arent processing all your procedures. So even if you dont know the payers fee schedules because they wont give them out, you should appeal if the total is too low, says Cobuzzi.
Carriers also inappropriately assign global periods. For example, sinus surgeries, esophagoscopy and laryngoscopy all have 0 global days, but other procedures still may be bundled to them, with a global package cited as the reason.
Cobuzzi relates a scenario where the otolaryngologist visited the patient in the hospital the day before performing an esophagoscopy (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). And even though the ENT billed for a hospital visit, the rounds made by the doctor the previous day were bundled into the 43200, when in fact the procedure has 0 global days, which means the rounds are actually billable. Some carriers also say the days following such procedures are part of the global period. But they clearly are not in the instance of 0 global days, Cobuzzi maintains.
Step 2: Keep Appeals Letters Simple
In another example of incorrect claim denial, a nasal endoscopy (31237, nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) was denied and a consultation was downcoded.
Cobuzzi handled the appeals process for the otolaryngologist in this [...]
