4/28/2016 1 Denial Mitigation and Management Whitney Horton, CPC, CCC AHIMA-Approved ICD-10 Trainer Director of Coding and Auditing First Professional Services Loveland, CO Objectives: • Focus on coding-related denials in the Physician setting ▫ Strategies to avoid denials ▫ Appropriately distributing denials ▫ Interpreting denial reasons k h l ▫ Taking the appropriate claim correction action ▫ Effectively communicating claim corrections
Transcript
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Denial Mitigation and Management
Whitney Horton, CPC, CCCAHIMA-Approved ICD-10 TrainerppDirector of Coding and AuditingFirst Professional ServicesLoveland, CO
Objectives:
• Focus on coding-related denials in the Physician setting▫ Strategies to avoid denials▫ Appropriately distributing denials ▫ Interpreting denial reasons
k h l▫ Taking the appropriate claim correction action▫ Effectively communicating claim corrections
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Denial Mitigation and Management
• Mitigation
▫ Front end Be mindful of correct coding, coverage policies,
NCCI edits, maximum units, etc.., ,
Denial Mitigation and Management
Management• Management
▫ Back end Even the seemingly cleanest of claims can fall
victim to non-payment. Make sure the second try’s the charm by making the appropriate claim correction.
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Denial Mitigation and Management
• Mitigation▫ Front end Players: Coders, Providers
• ManagementB k d▫ Back end Players Coders, Billing Specialists, Providers
C i d Ed i & C li
Mitigation: Strategies for Avoiding Denials
• Continued Education & Compliance• Stay current on policy updates• Create tools• Research• Track and Trend• Communicate with key players• Recognize ICD-10 payer related issues
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Strategies for Avoiding Denials
• Continued Education
▫ Correct Coding is the first step toward ensuring the claim is appropriately processed and paid the first time around
Strategies for Avoiding Denials
• Continued Education▫ Correct Coding Webinars and trainings for difficult or confusing
coding areas Get input from coding staff
Coding meetings to discuss difficult casesCoding meetings to discuss difficult cases Ensure coding team is on same page Coding tools Compliance plan
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Strategies for Avoiding Denials
• Stay current on policy updates▫ Subscribe Do you work with clients in different regions?
▫ Go directly payer sites To verify coverage policies
T h k f d t i ht h To check for any updates you might have missed
▫ Make a list of your most common codes with local and/or national coverage policies
Things to considerg Different regions Policy updates implementation dates
Strategies for Avoiding Denials
• Create Tools
▫ These will also serve as useful training tools
When new hires and new coders don’t have to reinvent the wheel work flow is more efficient reinvent the wheel, work flow is more efficient and correct coding and clean claims can more easily be ensured.
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• Create ToolsH i i f h d b f l
Strategies for Avoiding Denials
▫ Having a piece of paper handy can be useful as a reminder for new updates, but housing tools electronically allows them to be easily shared and updated. Excel works well because different information can be stored on different sheets while allowing you to only have 1 item open on your screenhave 1 item open on your screen. Store centrally in a shared location. Assign a
leader to make or review any changes and/or additions.
Track coverage policies for common codes and regions…
Override when performed at different levels , most likey pt will
carry dx for lumbar spine disorder(s) and dx for SI disorder(s)
64483 20551 Do not override when performed for pain at same level/site
93975‐93976 76700‐76705
Override only when significant 2D grayscale imaging of structures
outside of vasculature are examined and documented in addition
to duplex examination of vasculature
Track documentation and coding tips that have come up in training, continued education, or appeals…
CPT RANGE DESCRIPTION CODING AND DOCUMENTATION TIPS
64470-64484 Transforaminal ESI Documentation must state that approach was transforaminal. Codes are per level (L1-L2= 1 level)
62310-62311 ESI Documentation should state approach other than transforaminal- commonly translaminar will be used.
MULTIPLEMAGNETIC RESONANCE ANGIOGRAPHY
Documentation must mention 1 of the following: MIP, Volume Rendered Images, Surface Shaded Rendering, 3D reconstructed images
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R h
Strategies for Avoiding Denials • Research▫ Do some good ole fashioned research when
necessary Set aside some time each week to look into
things you feel uneasy about.
Look for information from reputable sources CPT Assistant AHIMA Specialty Organizations
Strategies for Avoiding Denials
• Track and Trend
▫ This is key, and often it is an intention that is never made a reality Always keep a record.Always keep a record.
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Track and Trend
Strategies for Avoiding Denials • Track and Trend▫ Keep a record of denials that can easily be
sorted by denied CPT and denial reason. If the same procedure(s) are repeatedly coming back for the same reason, why? Was the service coded incorrectly? Were the ICD10 codes assigned incorrectly? Is the documentation lacking?
C i
Strategies for Avoiding Denials
• Communicate▫ Use your trends to educate
Was the service coded incorrectly?▫ Provide education to the coder(s) ▫ Add the details to a coding tool
Were the ICD10 codes assigned incorrectly?▫ Provide education to the coder(s) ▫ Add the details to a coding tool
Is the documentation lacking?▫ Educate the Provider
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• Communicate
Strategies for Avoiding Denials • Communicate▫ Consider the most effective way to
communicate when errors are found in denials Coders Should the whole department be involved? Is only a one-on-one required?P id Providers Can you get them in a room and meet face to face? How can you make it stick? ($)
Strategies for Avoiding Denials
Denials and ICD-10
• Mitigating denials in the face of ICD-10▫ Be aware of poorly updated LCDs and NCDs
If you find such a policy, speak up!h // / di /C di / C 0/ https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-Provider-Contact-Table.pdf
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Denials and ICD 10
Strategies for Avoiding Denials
Denials and ICD-10• Do you just need to refile?▫ Was a policy updated with a difference in
effective date and implementation date?• Was a policy updated and codes were
removed or changed?removed or changed?▫ Check the revision dates and verify which
codes are valid during which periods of time.
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So…you didn’t get paid?
What now?
Appropriately Distributing Denials
Define the ‘why?’
▫ Coding related? If not coding related, are these filtered out? If yes, who is responsible for filtering?▫ Billing/support staff?▫ Billing/support staff?▫ Software?
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Appropriately Distributing Denials
• What does the work flow look like in your office?▫ Who gets the EOB initially? Billing Specialist? Coder?
▫ How is information communicated between d t t ?departments? Electronically? Paper? Verbal?
Appropriately Distributing Denials
Communication is Key
• Who are all the players?• Is information being communicated
effectively?• Is communication efficient?• Is communication timely?
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Communication is Key
Appropriately Distributing Denials
Communication is Key• Who are all the players?▫ Billing Specialists Role?
▫ Coders Role?Role?
Are the details of each role outlined in a formal process and procedure for the organization?
Communication is Key
Appropriately Distributing Denials
Communication is Key• Is communication effective?▫ Are denial reasons being appropriately
communicated? Is the claim adjustment reason consistently
being interpreted and conveyed accurately?▫ Don’t play telephone
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Appropriately Distributing Denials
Communication is Key• Is communication efficient?▫ How is information communicated? Paper, email, shared files, work queues?
D f l th i i ffi i t? Do you feel the process is inefficient? Propose a new plan in writing
Communication is Key
Appropriately Distributing Denials
Communication is Key• Is communication timely?▫ Do the players know how much time carriers
allow for appeals and corrected claims?▫ Set standard timelines for follow-up on in-
progress denialsprogress denials▫ Set electronic alerts if available as reminders to
follow-up on outstanding accounts/claims
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Interpreting Denial Reasons
• Glean as much information as possible from the EOB
• Claim adjustment reason codes:▫ http://www.wpc-
edi.com/reference/codelists/healthcare/claidj t t d /m-adjustment-reason-codes/
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Interpreting Denial Reasons
• Don’t play guessing games and risk additional subsequent denials▫ Denial reason sound bogus?
Make a call!
Interpreting Denial Reasons
• Most common coding-related denial reasons▫ CO50 Not medically necessary
▫ CO97 Bundled
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Taking the Appropriate Claim Correction Action
Medical necessity• Medical necessity▫ Review LCDs, NCDs Don’t just review the ICD10 code lists, review
the coverage guidance in its entirety
There may be important details regarding requirements that cannot be captured in an ICD-10 code and may require records to be sent and potentially a letter clearly outlining that the patient has met the requirements as described.
Taking the Appropriate Claim Correction Action
• Medical necessityMedical necessity▫ Make sure the ICD10 code is supported by
documentation Resist the temptation to use an ICD10 code that
is covered by the LCD but only ‘sort of’ fits the documentation
If you feel the provider has neglected to include If you feel the provider has neglected to include something in the record and the record is therefore incomplete, consider requesting an addendum (if timely enough)
If you feel the LCD is lacking, contact CMS.
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Taking the Appropriate Claim Correction Action
• Be wary when requesting addendums when necessary.• Use reputable resources to know when an
addendum may/should be requested and review methods for appropriately requesting an addendum.
http://library.ahima.org/doc?oid=301357#.VxAHq9QrJpg*Can be accessed by AHIMA members only*
Taking the Appropriate Claim Correction Action
• Bundling▫ What is being bundled? Same day services?
Services provided in the global period of previous services?previous services?
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• Bundling
Taking the Appropriate Claim Correction Action
• Bundling▫ Is a modifier appropriate? Is the service denied as bundled distinct and
separately identifiable from the primary same day service(s)? Add a modifier 59, XE, XP, XS, XU to the
secondary code secondary code. Find literature to support your stance▫ Specialty organizations
• Bundling
Taking the Appropriate Claim Correction Action
Bundling▫ Is a modifier appropriate? Does the service denied as bundled qualify to be
separately billed within the global period of a previous related procedure? Add a modifier 78 or 58
Does the service denied as bundled qualify to be Does the service denied as bundled qualify to be separately billed within the global period of a previous unrelated procedure? Add modifier 79 or 24
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• Bundling
Taking the Appropriate Claim Correction Action
Bundling▫ Is a modifier inappropriate? Should the code reflecting the secondary
service not have been reported?
Just because a modifier override is allowed does not always mean it is supported.not always mean it is supported.
If a modifier override is not supported, remove the code for the secondary service.
Provide education to coding staff
Taking the Appropriate Claim Correction Action
• Appeal letter ▫ State your position Create templates to help you with your most
common denials Be sure to update information in letters as
policies are revisedpolicies are revised
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Taking the Appropriate Claim Correction Action
• Appeal letter Letters can:
Supplement medical necessity appeals▫ Recall: requirements that cannot be captured in
ICD10 code Provide justification for a unbundling 2 services
using a modifier Explain why an unlisted code was utilized
Doctor’s Office123 Doctor Road
Anywhere, CO 123451-800-123-4567
May 5, 2016RE: Doe, JaneDOB: 1/1/1900DOS: 3-15-16To Whom It May Concern:
This letter is in appeal to your nonpayment of endovenous ablation therapy of incompetent vein, extremity, percutaneous, radiofrequency; first vein treated (36475) and injection of sclerosing solution; multiple veins, same leg (36471) performed on the above radiofrequency; first vein treated (36475) and injection of sclerosing solution; multiple veins, same leg (36471) performed on the above date(s) of service.
Per Medicare LCD (L34924), radiofrequency ablation of varicose veins is medically necessary in persons who meet the medical necessity criteria described below:
1. A documented 3-month trial of conservative therapy including graduated compression stockings with a minimum of (12-18 mmHg), weight reduction, therapeutic leg elevation, and an exercise program of calf muscle pumping activity with compression of the involved veins, which results in limited alteration/improvement of symptoms or findings without satisfactory endpoint, AND
2. Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and lesser saphenous vein and prominent tributaries and demonstrating the:a. Presence and Patency of the Deep Venous System.b. Absence of Deep Venous Thrombosis, andc. Documented Incompetence (reflux> 500m/sec) of the Valves of the Saphenous, Perforator or Deep venous systems consistent with the patient's symptoms and findings.the patient s symptoms and findings.
Additionally, per the LCD (L34924) sclerotherapy is medically necessary for the treatment of small to medium-sized veins (3-6mm) for persons who meet the medical necessity as described above.
Dr. Doctor treated multiple veins in both legs with radiofrequency endovenous ablation and sclerotherapy. Ms. Doe was documented to be experiencing swelling and pain in both legs associated with varicose veins. Ms. Doe meets all of the above criteria.
We have enclosed Ms. Doe’s operative report from 3-15-16, as well as her initial office visit and ultrasound from 3-1-16 for your consideration. Thank you for your prompt processing of our claim, and please do not hesitate to contact us if you have any questions or concerns.
Doctor’s OfficeCoder Name, CPC
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Doctor’s Office123 Doctor Road
Anywhere, CO 123451-800-123-4567
May 5, 2016RE: Doe, JaneDOB: 1/1/1900DOS: 3-15-16
To Whom It May Concern:
This letter is in appeal to your nonpayment of CPT 20551: single tendon origin/insertion injection performed on the same date as This letter is in appeal to your nonpayment of CPT 20551: single tendon origin/insertion injection performed on the same date as 20600: small joint aspiration/injection.
Per NCCI edits, these codes do bundle with a modifier override allowed when supported as separately identifiable procedures. We had appended a modifier 59 to CPT 20551 to demonstrate that this service was distinct and separately identifiable from the joint injection (20600). 20551 was performed on the left arm to treat the patient’s left lateral epicondylitis, while 20600 was done for right thumb CMC arthritis. These procedures are separately identifiable procedures as they were performed on different sites.
We believe your denial is in error and have included Ms. Doe’s office visit and procedure notes for your review.
We trust this explains our position in these matters. Please do not hesitate to contact our office should you have any questions. We look forward to you reprocessing and reimbursing this claim appropriately and in a timely manner, as required by Colorado insurance laws.
Sincerely,
Doctor’s OfficeCoder Name, CPC
Doctor’s Office123 Doctor Road
Anywhere, CO 123451-800-123-4567
May 5, 2016RE: Doe, JaneDOB: 1/1/1900DOS: 3-15-16DOS: 3 15 16To Whom It May Concern:
Enclosed please find an operative report for the above patient on the specified date. We have used an unlisted code to reflect aprocedure on this claim, [X9999].
Ms. Doe was noted to have [INSERT CONDITION] which required [INSERT PROCEDURE].
The patient underwent [INSERT PROCEDURE] performed by Dr. Doctor on 3-15-16 There is not an existing CPT to specifically reflect this service. These services should be valued similarly to CPT code [INSERT CPT AND DESCRIPTION OF SUGGESTED VALUATION].
Thank you for your prompt processing of our claim, and please do not hesitate to contact us if you have any questions or concerns.
Doctor’s OfficeCoder Name, CPC
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Effectively Communicating Claim Corrections
Consider Original Work Flow▫ Who gets the EOB initially? Billing Specialist? Coder?
▫ How is information communicated between departments?
El t i ll ? P ? V b l? Electronically? Paper? Verbal?
Effectively Communicating Claim Corrections
Building on Original Work Flow• Who makes the correction in the system?▫ Coder? Billing Specialist? If corrections are not made by the same
individual working through the denial, be thorough when communicating what changes thorough when communicating what changes need to be made in the system.
Keep comprehensive notes in patient’s accounts
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Other things to consider
Denial Mitigation and Management
• Other things to consider▫ Dividing responsibilities▫ Creating denial teams▫ Use of modifier GZ and GA▫ Updating outdated or ineffective processes
