Back End Revenue Cycle

Helpful tips and tricks to reduce denials

I did my first virtual webinar this week with my local AAPC chapter on a non-traditional medical coding topic. Although I have my medical coding certification, I have been working in Medical billing and appeals over the past 5 years. I really enjoy the troubleshooting aspect of it. Stuff gets submitted to the payer broken, error message ensues, then you try and “fix” it. This has been my new norm for the past 4+ years. I did it on the physician side for 2 years, now I am doing it on the hospital side…and even with the current state of healthcare, there are no signs of this process stopping any time soon. Although medical coding is prior to the health insurance claim being submitted to the insurance company, the point I made in my presentation was that it is helpful to have medical coders in different aspects of the healthcare business cycle. Think about it, Medical Coding professionals have to understand how and why codes are assigned to the claim for billing. With this information, your medical coding professionals, especially newer students, and might be able to help getting those “error messages” overturned. This can result in reimbursement for services for the facility or healthcare providers practice.

Why Denials continue to be a problem?

You can think of an insurance denial as an “error message” preventing payment to your providers office or healthcare facility. Knowing and understanding how to resolve a denial requires a deep understanding of medical coding and the codes that insurance companies use to communicate denied claims. These are often known as Reason and Remark codes and can be found here.

Your Medicare Administrative Contractors can be huge resources in this process. They often have free webinars that can provide you invaluable information on medicare guidelines for reimbursement, along with common denials that occur within their jurisdiction that might help in understanding claim resolution processes. The more you see and understand different types of denials you encounter, the more comfortable you will become with the process needed to obtain appropriate reimbursement for the services provided by your facility or physician.

Medical Necessity and Denials

It is so important to understand that medically un-necessary services are not payable. If you seek to obtain reimbursement for medically un-necessary services it is considered fraud. As certified medical coders we often hear the phrase “if it wasn’t documented, it wasn’t done”, and this definitely holds true for denials related to Medical Necessity. Know your coverage guidelines in order to evaluate what criteria are being used to determine whether a service is not considered medically necessary. For Medicare and Medicare Advantage plans, you will need to know your Medicare Local Coverage Determinations (LCD) and your National Coverage Determinations (NCD) as both of these criteria usually guide the rationale behind why coverage for the services provided were not payable. Remember LCDs are maintained by your Medicare Administrative Contractor so feel free to do a google search on who that is for your jurisdiction.

Commercial payers often have medical policies related to coverage of services.. so you might have to get information from the payer by placing a phone call to get direction on what and where to find coverage and the medical policies were used to make the denial determination so you can evaluate appropriate next steps on whether the information is appropriate to appeal or not.

If the clinical documentation doesn’t support the services rendered, provider education might be needed. If you cannot code what isn’t documented, and unfortunately, you cannot receive payment for the services rendered, payment for those services is not warranted. For more information on healthcare fraud and abuse, click here.

I hope you find this helpful. For more resources feel free to check out these links suggested by Winda Hampton in the July 2019 issue of Healthcare Business Monthly (AAPC Membership Required)

ICD 10 CM Guidelines 2020

CMS Internet Only Manual