# Appealing a Claim?



## jifnif (Aug 28, 2009)

I am questioning an appeal situation with Medicare.  Scenario is that our hospitalists were doing there own coding and now I am taking over that job.  I am having a lot of charges come back that they had incorrectly coded.  The rejection might state not medically necessary or something else.  While researching the necessity I have found that the E/M should be downcoded.  Can I appeal w/ a new CPT or even rebill with a new CPT?  Hope that is clear.  Thank you so much!


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## aguidry (Aug 28, 2009)

*Medicare Appeal*

Make sure it is done within 120 days of the denial date.  And documentation is the key to being successful.  Good Luck!


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## Teresa Collins (Aug 28, 2009)

I'm not sure who your Medicare carrier is, but Trailblazer has a "Reopening Request Form"  that allows you to correct errors in billing that are filed to Medicare.  It's on the Trailblazer website under "Appeals".  I'm not sure if this is the info you are looking for, but I hope it helps!

Teresa Collins, CPC


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## tippee (Aug 29, 2009)

You can appeal any denial with the supported documentation aka special report when the services were not considered of medical necessity.  Medicare is looking for support for the cpt codes which were used.  If you simply change the code you they will kick it back to you as a duplicate charge since it is on the same date.  

You have a lot of work ahead of you.  Good luck.  Been there.....done that.

I am new, what do I know.  I am unemployed.  

You are also in sales, keep track of what is not approved due to your work.  Figure out the percentage of previously denied, and now paid.  Now its your turn for reimbursement.


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## jifnif (Aug 31, 2009)

Thanks, I will check out trailblazer.  Also, I don't know if there was some confusion, but I know it will act as a dup if I change only the ICD 9.  I am referring to changing the CPT to a lower E/M code that is more suitable to the documentation.  So in that case, it is almost like a "new" claim.  I just want to make sure that I am not doing anything "illegal" by changing to a more appropriate CPT after a rejection from insurance/medicare.


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## Teresa Collins (Aug 31, 2009)

I think there is a place on the Reopening Request Form to change a CPT code.  You can also send a copy of the documentation to go along with the Form.  I think it is more appropriate to send in the form rather than just file a "new" claim.  Medicare will know you are trying to correct the claim when they look at the form. 

I hope this information helps!  

Teresa Collins, CPC


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## rthames052006 (Aug 31, 2009)

jifnif said:


> I am questioning an appeal situation with Medicare.  Scenario is that our hospitalists were doing there own coding and now I am taking over that job.  I am having a lot of charges come back that they had incorrectly coded.  The rejection might state not medically necessary or something else.  While researching the necessity I have found that the E/M should be downcoded.  Can I appeal w/ a new CPT or even rebill with a new CPT?  Hope that is clear.  Thank you so much!



Your Medicare carrier is the same as mine Highmark Medicare; they have a Redetermination Request form that you can fill out and "correct" the cpt code and if you want to send any documentation you can do so.

www.highmarkmedicareservices.com

If you have any issues/question don't hesitate to email me.


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## jifnif (Sep 1, 2009)

Thanks, that does help.  Just to be clear, this can be done after you have received a rejection from Medicare?  Just need to be crystal when it comes to this situation.    Thanks again.


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## rthames052006 (Sep 1, 2009)

jifnif said:


> Thanks, that does help.  Just to be clear, this can be done after you have received a rejection from Medicare?  Just need to be crystal when it comes to this situation.    Thanks again.



Yes.  You will need to put the claim # on this redetermination request.  Once you see a copy of the form you will see exactly what you will need to fill out.

If you need any help just email me.


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## jifnif (Sep 3, 2009)

Thank you.  Just wanted to make sure.


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