Cardiology Coding Alert

Hint: Educate your staff.

Working in healthcare, you already have a lot on your plate, so dealing with denials is the last way you want to spend your time.

“Denials are increasing. This has happened year after year,” said Jennifer Swindle, RHIT, CCS, CCS-P, CDIP, CPC, CIC, CPMA, CFPC, CEMC, AAPC Fellow, in a presentation titled “Top Denials and how to work them effectively and prevent them in the future” at AAPC’s 2023 virtual REVCON.

Take a look at some tips you can follow to keep denials at bay in your practice.

Tip 1: Identify Common Denials

Some practices may not think the resource investment required to appeal denials is worth the significant work costs. “Because of staffing issues, because of the work, a lot of times accounts do get adjusted off, because the dollar amount isn’t significant enough to pay for the appeals process,” Swindle said.

Practices should consider the number of times these adjustments are made and evaluate how those costs bear out.

Claims are denied for a variety of reasons, but some reasons are more frequently seen.

Swindle lists these common denials: duplicate claims; the patient has other primary insurance; the payer doesn’t cover the reported diagnosis; missing/incomplete/ invalid diagnosis; authorization issues; timely filing; modifier issue; the provider isn’t credentialed with a national provider identifier (NPI).

NPI credentialing can be especially tricky because providers no longer backdate their services, Swindle said, so practices may have a tough time securing payment in the period between when a provider starts working at an organization and when their credentialing comes through.

However, not all payers use denial codes in the same ways, and the denial codes selected may not show what providers need to do to correct the claim. Swindle noted that staff needs to be experts in navigating payers’ explanation of benefits (EOB) and payers’ websites because they may need to be able to “read between the lines.”

Top tip: If you can develop a relationship with a payer via your representative, you may have an easier time getting information that you need when you need it, Swindle said.

Tip 2: Double-Check Root of Duplicate Claim

“Duplicate claims may seem really easy,” Swindle said, but they can be really difficult because you always have to verify that there were two claims filed for the same provider and the same service, that it was an error on the organization’s part, and that the claims are truly duplicate.

“We don’t want to get any money that isn’t owed to us, but we don’t want to assume that money isn’t due because the denial code may say ‘duplicate claim,’” she said.

If the claim was corrected and made to an initial claim and refiled, but the bill type wasn’t updated, then the payer may not be able to see that the claim isn’t a duplicate.

Also, if you have a corrected claim but received payment on the initial claim, you may need to refund the money on the first claim so the payer can appropriately pay the corrected claim, she said.

You can adjust your billing system to trigger an alert to check whether a claim has already been filed for a service.

Coding tip: Appending the correct modifier can help curtail duplicate claims in some instances, like if a patient receives an electrocardiogram (EKG) twice on the same day by the same provider or a different provider, she explained.

Tip 3: Incorporate Education for Staff

Having the wrong insurance on record for a patient can lead to denials, which makes sense because carriers should be expected to pay only what they’re responsible for.

Make sure the staff interacting with your patients checks and verifies the patient’s insurance before an appointment. This is especially important because different commercial carriers may update their insurance at different times of the year — or the patient may have insurance coverage through an employer and thus their insurance may change with their employment.

“If it’s not being updated and verified, it’s very easy to send a claim out the door to the wrong insurance carrier,” she said.

Another common denial occurs when a patient has multiple insurances, and the practice may not have the primary and secondary coverage correctly categorized. Or, if the incident that brought the patient to the encounter was a vehicular accident or worker’s compensation claim, there may be an additional entity at play to pay.

Tip 4: Adjust Systems to Comb Claims

“Not covered with reported diagnosis” is another common denial, Swindle said, which ties back to medical necessity. This may happen with diagnostic testing, where a test is ordered by a physician or other qualified health professional (QHP) is performed at a hospital, whose claim is then denied.

Providers may not realize that this is happening; this is another situation in which Swindle recommends checking your billing or electronic health record (EHR) system to trigger alerts for medical necessity and to adjust your system so it receives coverage determination updates.

Similarly, make sure your EHR system is incorporating annual updates and other changes as soon as they go into effect.

Check out the display settings, too. Swindle noted that some denials are caused by coders submitting the wrong claims because their EHR software displayed the first part of the descriptor, which seemed accurate, but not the full definition. Payers also deny claims for invalid diagnosis codes because the codes selected aren’t expanded to the correct digit.

If you have a system in place for pursuing prior authorizations, ensure that the processes reflect reality. Swindle offered the example of a patient requiring surgery but getting a COVID-19 infection right before the surgery was scheduled. In this situation, the surgery gets postponed, and the prior authorization now does not reflect the actual date of the service.

Dive into your processes to make sure that all bases are covered for prior authorizations, including that the authorization number, if received, gets to the claim form.