Humana denials for not documented in medical record

lacykoch

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I work with an Orthopedic group and every time we send medical records for our claims to either Humana or Ortho Net, they deny the procedure codes stating that it is not documented in the medical record. It is clearly documented and we have even highlighted where it is documented and asked for review again. We have also appealed using the description of the CPT code itself. They are still being denied. Is anyone else having this issue and if so, how are you overcoming this?

Thanks for any insight!
 

honeybee

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I work in PT and we have found that these denials are related to bundling. We have tried everything from appealing them after the claims process, sending in notes with the claims on paper and even with these steps are only occasionally successful in getting those codes paid and it sometimes took months and months of follow up or a response back from the plan with very few denials being over turned anyways. We even got our network contracting company involved and were initially told this was a known issue and would be corrected but eventually nothing panned out and we had no success going that route either. Even the times a bundled code would go through and pay, Humana will eventually end up recouping it for no documentation to support the code. Finally what we did was just add a billing rule to our system so that the code 97530(theraputic activity) would not go out on our claims for this specific payer or if it was billed and denied we would just write it off and created a special adj code for this. They also bundle 97002 and 97004 (re-evals), those codes we do not restrict billing for because we have to do re-evals periodically however we generally just end up adjusting them as appealing is not usually worth the time and effort with the large amount of claims we have. Obviously I don't feel we should have to do this but we just haven't found a successful way for them to review our documentation in order to appeal the bundling denials and it was not worth it.
 

npricercm

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I work with an Orthopedic group and every time we send medical records for our claims to either Humana or Ortho Net, they deny the procedure codes stating that it is not documented in the medical record. It is clearly documented and we have even highlighted where it is documented and asked for review again. We have also appealed using the description of the CPT code itself. They are still being denied. Is anyone else having this issue and if so, how are you overcoming this?

Thanks for any insight!

I have found that sometimes if you call and talk to the customer service rep at the payor and ask them to review why the claim isn't being paid, more information sometimes comes available by way of other departments notes or references to internal processing procedures. I worked for an insurance company as well as a free standing clinic and sometimes asking questions can clarify an insurance processing issue.

I have also called the network provider rep and asked for assistance in getting claims paid and they can be very helpful in reviewing the contract for any inclusions or exclusions in the insurance processing system. Sometimes contracts get updated incorrectly and do impact reimbursement. If the network reps don't see anything they will forward a request to the payment side of the payor and ask them for clarification on your behalf.

Sometimes a coder, never touches a claim at a payor. The claims run through the payment process and examiners check to see if the claim follows all their payment/reimbursement criteria. It is not by any means a perfect system and as coding changes, payor policy changes and the examiner reviewing your claim may not be applying the most recent updates.

My question would be "What is not being documented?" what is the insurance looking for? Is a diagnosis? Is it a cpt code? Is it a lab result? Is it results of a previous procedure that determines whether or not to bill a more extensive procedure? Is it a stall tactic to delay payment for a clean claim? If other clinics are getting the same denial than there may be something wrong with the way the insurance is processing the claims and no one has put two and two together to identify the insurance processing issue? The squeaky wheel gets oiled first, so protest loudly and often if you are submitting a clean, compliant claim:)

In my experience, if I have a clean claim then I would do whatever I could to get it paid. You just have to find the right person to talk to at the payor level if your submission is compliant and correct according to the payor policy.

Good Luck!
 
Last edited:

lacykoch

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I work in PT and we have found that these denials are related to bundling. We have tried everything from appealing them after the claims process, sending in notes with the claims on paper and even with these steps are only occasionally successful in getting those codes paid and it sometimes took months and months of follow up or a response back from the plan with very few denials being over turned anyways. We even got our network contracting company involved and were initially told this was a known issue and would be corrected but eventually nothing panned out and we had no success going that route either. Even the times a bundled code would go through and pay, Humana will eventually end up recouping it for no documentation to support the code. Finally what we did was just add a billing rule to our system so that the code 97530(theraputic activity) would not go out on our claims for this specific payer or if it was billed and denied we would just write it off and created a special adj code for this. They also bundle 97002 and 97004 (re-evals), those codes we do not restrict billing for because we have to do re-evals periodically however we generally just end up adjusting them as appealing is not usually worth the time and effort with the large amount of claims we have. Obviously I don't feel we should have to do this but we just haven't found a successful way for them to review our documentation in order to appeal the bundling denials and it was not worth it.

We actually have the same problem with the 97530 as well, We adjust them off the same as you do. Unfortunately, we were also told that they had a glitch in their system and denied 97530 incorrectly, but I have never seen them pay it. Thanks for your response!
 
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We are having the same problem. I'm actually writing the procedure code next to the paragraph where they can find the code and they're still denying. What in the world??????
 
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