Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 20, 2005 PDF

You won't have much room for error after Jan. 1

You'll have to submit all of your information for an appeal at the Qualified Independent Contractor (QIC) level starting in January. If you leave out important documents that could turn the tide, you won't be able to add them after the QIC level.

Until now, providers have tended to wait until they got to the Administrative Law Judge (ALJ) level to submit any additional evidence, notes attorney Alan Reider with Arent Fox in Washington. The evidence you submit at the carrier level won't do much good if it's inconsistent with the carrier's policy, but you'll still be better off submitting information to the carrier instead of waiting until the QIC.

Do this: You should be working to improve your processes for gathering medical records and sending them in, says Tammy Tipton, president of Appeal Solutions in Blanchard, OK. If you have any "procedural hurdles" to getting all your information together quickly, deal with them now, or you could lose out next year. You may need to improve communication between different departments in your office, she adds.

Tip: Make sure all the documentation you submit includes all the information specified by the CPT descriptor as well as your carrier's local coverage determination, advises Deborah Churchill, president of Churchill Consulting in Killingworth, CT. The documents should have the beneficiary's name on each page.

Example: Oftentimes, a radiation oncology treatment center will have a multi-page foldout chart with the patient's name on the first page, Churchill notes. One of her clients had $70,000 in daily treatment charges denied because the office photocopied the chart without including the patient's name on each page. Once the carrier found that this was a clerical error, it reversed the denial, says Churchill.

The law says that if the QICs deny your appeal, they must provide the scientific or clinical evidence they relied on, says Reider. But it remains to be seen whether the QICs will really provide any useful information or feedback. The information may allow you to focus your appeal more clearly and respond to the points the QIC makes.