There’s usually a reason and a solution for every denied claim.
Claim denials are inevitable. The first step to work through them is understanding the most common denials, such as:
- global denials;
- multiple frequency denials; and
- no plan coverage denials.
Unbundling occurs when a service is billed using individual codes when a single, all-encompassing code exists. For example, a provider might order a lipid panel; however, instead of billing 80061 Lipid panel, the provider bills each test separately.
Another example of a common bundling mistake is reporting 76000 Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time, other than 71023 or 71034 (eg, cardiac fluoroscopy) or 76001 Fluoroscopy, physician or other qualified health care professional time more than 1 hour, assisting a nonradiologic physician or other qualified health care professional (eg, nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) with any arthroscopic procedure. These CPT® codes are considered part of the primary code, and are not separately reimbursable.
Some codes allow for modifiers to undo the bundling. For example: A child comes in for 5-year-old physical. At the same visit, the physician determines the child needs to be treated for an ear infection. Without the correct modifier (modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), this additional service will bundle into the exam code. Do not use a modifier to improperly unbundle codes, however. Services considered part of a primary procedure should not be billed separately.
Become familiar with the rules for which codes cannot be billed together. An excellent resource is the National Correct Coding Initiative Policy Manual, which provides explanations and examples to assist with bundling issues.
Global denials occur when a surgery is done in a provider’s office within 0-90 days (depending on the procedure). For example, a patient coming in for follow-up care or dressing changes cannot be billed for a separate visit that occurs within the global days assigned to the primary service.
There are a few exceptions to this rule. One example is an unplanned return to the operating room. For instance, a patient goes to the operating room for a hernia repair. During the post-op period, the patient develops bleeding at the incision. The return to surgery is reimbursable with the appropriate modifier
(modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).
Multiple Frequency Denials
Multiple frequency denials (MFD) require you to determine if there is something within the claim to be fixed. The first thing to verify is if it is a duplicate claim issue or a corrected claim issue:
- If it is a duplicate claim issue, simply make sure one of the claims is paid.
- If it is a corrected claim issue, call the insurance company and politely point it out so they can reprocess the corrected claim.
- If it is an MFD, that means more than the normal or allowed units of service were performed for the reported CPT® code.
An MFD usually requires a written reconsideration and medical documentation to show what was done because a medical review is required to overturn it. Using a modifier sometimes triggers a review request, as well.
Plan Language Denials
Plain language denials are directly related to patient benefits. Patients should understand some basics about their insurance plans, but it is up to the provider to be familiar with coverage for a specific service or supply. It is best to verify coverage before the provider performs the service. There may be special rules, such as prior authorization or a pre-service review requirement, before the insurance will pay. If things are not done per the patient’s plan, the service will not pay, and in most cases no appeal will change that issue. It is always better to prevent this issue instead of trying to fix it after the fact.
A Win-win for All
It’s important for coders and billers to understand reimbursement from the insurance company’s perspective. Learning the reimbursement side allows a medical office to bring more money into the practice and keeps operating costs lower with fewer appeals on the back end. Understanding reimbursement also allows for better relationships between the practice, patients, and the insurance companies.