When providing medical coding services, coding and billing staff often deal with claim denials and appeals. Claims get denied mainly due to incomplete or missing billing information, coding errors, insurance coverage exceeded limits, and treatment not covered by certain plans. When a health insurance claim gets denied, patients as well as providers have to cover the cost, leading to unexpected medical bills.

While a denied claim is when the health insurer has decided not to cover a claim and the claim will not be paid, a rejected claim is when the claim does not get processed, due to an error in information. For any rejected claims, practices should resubmit the claim with the right information the insurance company wants. Successfully appealing claim denials can increase the chances of being reimbursed for the services provided.

What Can Be Done to Avoid Claim Denials and Resubmissions

Learn patient’s insurance plan well

Know everything about your patient’s insurance before consultation – what treatment it covers, how long they can receive it, and any limits on benefits. Conduct eligibility verification by directly calling up the carriers to verify co-pays, co-insurances, claims mailing address, deductibles, patient policy status, type of plan, coverage details, and more.

Code it correct for documented procedures

Assign the right procedure and diagnosis codes based on what is documented. Never code for anything that is not documented. Make sure that the list of procedures performed clearly reflects what occurred in the operating room. Read the operative note to reveal separately reportable procedures. Review the documentation to ensure that the codes assigned are correct.

Use the right modifier to unbundle procedures

While documenting two or more services done during an encounter, a modifier should be used to unbundle those procedures and show how they are separate from each other. The appropriate modifier depends on what was done. This could be a procedure on different areas of the body or a procedure performed by another provider. To select the right modifier and to avoid bundling issues, check the National Correct Coding Initiative (NCCI) table and the procedure-to-procedure (PTP) edits before submitting the claim.

Assign diagnosis and procedure codes based on age

Consider the patient’s age while using codes. For instance, for preventative medicine coding in the pediatric population, for ICD codes, newborn health is separated by the first eight days, eight to 28 days, and 28 to one year for diagnosis codes. However, CPT coding is the same for all infants.

  • Preventive medicine visit for a 10-year-old

99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)

  • Same visit for a 12-year-old

99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years).

While the above steps will help physicians avoid claim denial to a great extent, what can they do in case a claim is unfortunately denied in spite of being cautious? Physicians can always appeal a claim denial. When appealing, they must ensure that the denial isn’t part of any contractual adjustment to avoid it becoming a write-off. The claim must be resubmitted for reconsideration within the time frame allowed, ensuring that all the missing details are filled in. The appeal process must be in keeping with the insurer’s protocols. It is possible that you may have to undergo multiple levels of appeals and even a grievance process to win the claim ultimately.

Train your practice’s billing staff or outsourced medical billing service to carefully follow up on the denials, and check which types of denials are affecting your collections and cash flow the most. Make sure your medical billing process also involves AR analysis to evaluate the current accounts receivable status and identify the areas for improvement.