Primary Care Coding Alert

Get organized for easier, more productive appeals When your practice receives a denial on a claim, do you have a plan of action for dealing with it? If not, you could be losing out on reimbursement you might win back rather easily with a streamlined appeals process.

Reporting proper CPT and ICD-9 codes is the most vital responsibility of the coder, but knowledge of denials and appeals is also important. Even if you don't deal with appeals directly on a daily basis, cleaning up your reporting can help your office's bottom line.
 
Practices lacking an appeals strategy should implement one immediately, or risk losing out on further reimbursement. Use this six-step plan as your guide to formulating an effective appeals process.
 
If your office already has an appeals procedure, check it against this plan to see if your practice is getting everything it can out of appeals. 1. Focus Your Appeals Efforts Review past data on appeals and determine patterns that have led to repeated denials in specific areas, says Rebecca Buegel, RHIA, director of HIM and privacy officer at Casa Grande Regional Medical Center in Casa Grande, Ariz.
 
For example, if you are having trouble with a payer reimbursing for a separate E/M service the physician deems necessary after a preventive exam on a patient, focus on forming a solid appeal for this situation.
 
2. Respond Appropriately to Denials Denials are classified using one of four Explanations of Benefits (EOBs); one EOB will appear on each refused claim. Refer to "Read EOBs Before Responding to Denials" on page 3 for tips on dealing with EOBs from payers. 3. Document, Then Document Some More The more information you present in your appeal, the more likely it is that your claim will be accepted upon resubmission. Appeals should always include supporting documentation for your coding and billing choices, and information from outside sources backing up your claim is also helpful.
 
Insurers are more likely to consider appeals evidence from sources such as the CPT manual, the ICD-9 manual, CPT Assistant, the Coder's Desk Reference, the National Correct Coding Initiative edits (even though they technically apply to Medicare, they support your arguments), Medicare carriers' local medical review policies (even though they don't bind insurers, they support your arguments) and your national specialty society.
 
Use specific cases as examples, but deal with the encompassing issue - bundling, E/M requirements, etc. - so the carrier can't deny you on the same type of service again. 4. Get Personal Without Getting Mean Before you resubmit a claim, call the [...]