Denials & Denial Management - Articles

Why You Should Be Looking Up Medical Codes Online
February 23rd, 2023 - Find-A-Code
Medical coders, billers, and auditors all rely on accurate codes to do their jobs. Unfortunately, none of them can get by with just one set of codes. There are multiple sets encompassing tens of thousands of codes covering just about everything in healthcare. That means constantly looking up codes – even among those with excellent memories. The important question is this: where are codes being looked up?
When a Non-Covered Service Claim Gets Paid
February 22nd, 2023 - Ronald Hirsch
It happens more often than you might expect. One topic I often speak about is patient notices. Don’t we all love them? We all know no one really reads them until something goes wrong, and then you better be darn certain you did it right. Recently I discovered...

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5 Things Capable of Slowing Down Medical Reimbursements
October 31st, 2022 - Find-A-Code
The U.S. healthcare system relies on a somewhat complex billing and payment system. The system is designed to bridge the gap between patients, providers, and payers. When everything works as it should, reimbursements from payers to providers flow freely. But if just one thing goes wrong, reimbursements can be delayed.
Correct Place of Service Codes are Not that Big of a Deal!
August 2nd, 2022 - Chris Woolstenhulme
Have you heard the saying, "I am getting paid, so I must be doing something right!" Claims get processed and paid incorrectly all the time; the fact is you may be doing something wrong even if you are getting paid! If you don't understand how the physician fee schedule works, ...
Managed Care Organizations Use CMS Tools to Identify Outliers
June 1st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Managed Care Organizations (MCOs) include risk-adjusted plans whose funding is based on the health status of their beneficiaries. Government-funded MCOs use CMS information to search for suspected cases of fraud and abuse.
Intersegmental Traction — What’s Happening with Roller Tables?
May 20th, 2021 - Wyn Staheli, Director of Research
Intersegmental traction therapy via the use of roller tables has been used by doctors of chiropractic for many years. Recently, questions have arisen regarding the appropriate billing of roller tables. This is largely due to the statement published in the July 2020 CPT Assistant published by the American Medical Association (AMA). Which code should you really be using?
58% of Improper Payments due to Medical Necessity for Ventilators
April 29th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...
Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K
April 12th, 2021 - Wyn Staheli, Director of Research
Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.
Payment Adjustment Rules for Multiple Procedures and CCI Edits
July 9th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...
Denials due to MUE Usage - This May be Why!
January 7th, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
October 18th, 2019 - Namas
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
The New ICD-10-CM Code Updates Are Here — Are You Ready?
October 1st, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases. Chapter 2: ...
Healthcare Common Procedure Coding System (HCPCS)
August 13th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
Are These Problems Hurting Your Practice?
July 22nd, 2019 - Wyn Staheli, Director of Research
There are many things that can be missed when trying to run an effective and profitable practice. This article covers some important tasks that are often overlooked such as not reviewing your payer contracts or failing to check eligibility.
Denial Management is Key to Profitability
July 15th, 2019 - Wyn Staheli, Director of Research
A recent article by Modern Medicine cited a report by Becker’s Hospital Review which stated that it costs approximately $118 per claim to resolve a claim denial. Granted, these were hospital claims, but the process is essentially the same for outpatient services. In fact, you could say it is...
What Medical Necessity Tools Does Find-A-Code Offer?
June 13th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
What is Medical Necessity and How Does Documentation Support It?
April 23rd, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
Understanding NCCI Edits
February 20th, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
Are You Protecting Your Dental Practice From Fraud?
January 10th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...
Pricing for ASC’s and APC’s
August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
Q/A: I am Having Trouble with a Claim Rejection on my PI Claim. What do I do?
April 12th, 2018 - Wyn Staheli, Director of Research
Question: I have a patient that was involved in a PI case. His lawyers are asking that we bill his insurance company first. This particular patient has xxxx insurance and the clearing house is rejecting the claim based on "ERROR 3430-Invalid principal diagnosis code." We lead with diagnosis code V43.52XA, could we change the position of the V43.52XA code? Or should we submit a paper claim for the case instead?
Q/A: Which Modifiers to Use When Billing 44005 and 36556 Together
March 26th, 2018 - Chris Woolstenhulme QCC, CMCS, CPC, CMRS
I have a denial for 44005 and 36556 being billed together. I added modifiers 51, 59, and Q6 to 36556 but I am afraid it will deny again?
Avoiding D9 Denials
March 26th, 2018 - Nicole, QCC
The following is according to WPS. Please make sure what is bold below is entered verbatim on the second line of the "Remarks" section. This should be the only thing on the second line of remarks: Patient control nbr - If you are changing or adding a patient control number Admission hour - If you are changing or adding the admission ...
Q/A: Why is Code 99080 Being Denied when Billed with an E/M Service?
March 21st, 2018 - Wyn Staheli, Director of Research
In order to understand and answer the question, "Why code 99080 is being denied when billed with an E/M Service, it is important to first review the requriements of selecting the appropriate level of Evaluation and Management service and how that relates to reporting a 99080 special report service. Continue reading for better understanding.
Documentation Tips for Ostomy Supplies
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies....
Preventing Denials for Home Blood Glucose Monitors (BGM)
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...
Preventing Denials for Therapeutic CGMs and Related Supplies
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies
Preventing Denials for Manual Wheelchairs
March 8th, 2018 - Medicare Learning Network
The Medicare Learning network provides guidance on how to prevent denials for Manual Wheelchair Bases....
Preventing Denials for Lower Limb Prosthesis
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them: For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation. For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
Insufficient Documentation Errors
January 29th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
According to CMS ICN 909160, claims are determined to have insufficient documentation errors when the medical documentation  submitted is inadequate to support payment for the services billed, meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims ...
Revenue Cycle 101: Reduce your Denials with These Tips
January 24th, 2018 - Ranadene Tapio, MBA, CMRS, CMC
Your practice seems to be doing everything right. You have a team in place, established your RCM process and you’re submitting claim after claim – but your denial rate isn’t going down....
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
January 18th, 2018 - Wyn Staheli, Director of Research
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
Big Data & Facility Audit Complex Reviews
September 29th, 2017 - Shannon Cameron, MBA, MHIIM, CPC
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
New Policy from UnitedHealthcare
September 22nd, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA
In the June 2017 UHC Network Bulletin, there was an article that addressed UHC's decision to no longer pay for consultation services.....
Changes to the Medicare Appeals Process
August 25th, 2017 - Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
23 RCM questions you should ask when reviewing a medical billing company
September 29th, 2016 - Ango Mark
So, you have considered taking on the challenges of finding the best medical billing company for your medical practice. We should all by now know that the healthcare industry’s reimbursement laws aren’t going to stay put and be as they are. The changes they undergo are constant and...
When patient doesn’t pay health exchange premium, you may be left holding the bag
September 3rd, 2014 - Scott Kraft
One of the issues surrounding implementation of the Affordable Care Act (ACA) that impacts physician billing and payment and hasn’t gotten a lot of attention is what happens when a patient buys an insurance plan under the exchange, but then stops paying the premium. The answer may end up...
CMS puts the brakes on RAC audits for now, and implements changes for when they return
April 30th, 2014 - Scott Kraft
Good news for physician practices that don’t like getting demand letters and record requests from Recovery Audit Contractors (RACs). All those requests will stop by Feb. 28 on orders from CMS. RACs will be back once CMS awards new RAC contracts, but those awards may not come soon. When they...
6 ways to stop filing duplicate Medicare claims
December 4th, 2013 - Scott Kraft
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
Look for standard use of remittance advice codes in 2014
September 6th, 2013 - Scott Kraft
Confusion over how to respond to electronic remittance advice (ERA) will hopefully decline in 2014, thanks to efforts from the Council for Affordable Quality Healthcare (CAQH) to streamline and standardize how payers use ERA codes to convey why your claims are being denied or rejected. These...
No Claim Left Behind
March 22nd, 2013 - Shannon Bosley
Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little dance that I do! Why not? We need to get...
Why Get Into Medical Billing?
March 22nd, 2013 - Debra Sanders
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over 15 yrs and still learn something new every day. I even learn something I...
Graphical Coding as part of EMR clinical workflow
March 22nd, 2013 - Robert Jordshaugen
The way to ensure a high performing EMR implementation is to fundamentally rethink processes to match what is technologically appropriate, rather than automating existing workflows. Instead of using the existing HIT EMR systems from the major vendors as the workflow driver, start with a sample of...
Using denial tracking to improve collections
April 10th, 2009 - Codapedia Editor
Here are some examples of denials that a practice should track to be sure that they are paid correctly by the insurance company. Set up a denial type for each of these. Fee Schedule Issues: Wrong amount paid per the contracted fee schedule. May be too high or too low Modifier 80...
Denial tracking
March 30th, 2009 - Codapedia Editor
Claims denials have the following outcomes, none of them good: Collection of revenue is delayed Collection for the service never happens Staff members spend time and energy researching and resubmitting claims The denial is lost in the A/R system and never worked There are...
March 30th, 2009 - Codapedia Editor
One of the most common sources of denials in physician practices is "patient not eligible for this date of service." The patient presents with an insurance card, the office copies the card, and stores the information. The practice provides service, and perhaps collects a copay, and then...
How to analyze and diagnose a low collection rate
March 5th, 2009 - Elizabeth Woodcock
Woodcock & Associates has provided a diagnostic tool for you to download. Click the Resources link above to get the PDF file.
The insurance company denies urinalysis as incidental
February 15th, 2009 - Codapedia Editor
In 1864, Anthony Trollope said, "Perhaps in no career has a man to work harder for what he earns, or to do more work without earning anything." And this was before Relative Value Units and bundling edits! There are commercial payers who do not use the National Correct Coding Initiative...

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