Cardiology Coding Alert

During her Virtual HEALTHCON 2020 presentation “Decrease Payer Denials for Increased Revenue,” speaker Stephanie M. Sjogren, CCS, HCAFA, CPC, CDEO, CPMA, CPC-I, shared expert advice to help you prevent denials in your practice. Suggestions include having a provider advocate, creating detailed payer contracts, and trending and tracking denials.

You should also have a provider representative, advocate, or other direct contact at your payer, Sjogren says. Get a specific name of someone you can contact via phone or email.

“Mistakes and misunderstandings in configuration, testing, deployment, contract ambiguities, and edits will cause denials,” Sjogren explains. If you call the provider resolution number, they may go over one or two claims with you, but they might not understand that the problem is a pattern.

“If necessary, stipulate in your contracts that you will have a contact outside of the provider helpline available after traditional routes of contact have failed,” Sjogren adds.

Carefully Conduct Denial Research

When you research denials and trends, always ask questions and request details. “This is where the provider representative is paramount in helping you complete the task more accurately than the call center,” Sjogren says.

Examples of questions you can ask include the following:

Question 1: Do you require modifier RT (Right side), modifier LT (Left side), or other anatomic modifiers on this code?

Question 2: Do you have any diagnosis code restrictions?

Question 3: Do you have a medical or reimbursement policy that states your rationale for restricting a diagnosis, treatment, procedure, or other criteria?

Question 4: Are your edits sourced to the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), or any other professional associations?

You should always be specific, Sjogren reiterates. “If you have a denial that is not sourced to anything you can find on the payer’s website, through AMA, Medicare, or the LCD/NCD, you want to ask for its rationale and source.”

Sjogren also emphasizes you should never immediately appeal a denial.

Many of the payers only give you one appeal chance, and you don’t want to waste that chance on a question, Sjogren explains. Oftentimes when they answer the question, it will be generic, and you won’t have any more rights.

Remember: “Any health plan must make available, upon request, and in some cases publicly, the details of any policy or edit that will result in a claim denial,” Sjogren says.

Trend and Track Denials in Your Practice

Since you can count on denials for many general reasons such as coordination of benefits (COBs), eligibility, or authorizations, you should train the front-line staff in your office to handle these issues proactively to avoid unnecessary denials, Sjogren says.

You should also trend and track your denials, Sjogren explains. Categorize your denials and who will handle them.

You can follow these simple steps:

• Look at overall trends and possible correlations between multiple denials to see if you can find the root of the problem. You should not rely on a customer service representative to do this for you, but if you do call the customer service line, you should ask them what denial codes they are using, Sjogren says.
• Become familiar with the payer coverage policies and make sure you are providing the necessary documen­tation.
• After you’ve found the root cause of the denial, you can quantify how many of that denial code you are seeing.
• Next, run a claims report based upon the data you found. “If you have more than 5-10 claims with the same or a similar issue, do not call to have each one reprocessed,” Sjogren says. “Instead, contact your provider advocate and work on finding a mutual agreement for claims processing and fixing the root cause issue.”
• Follow up with your claims reports to ensure the issue has been fixed and straggler claims have received manual intervention.

Editor’s note: Want more great info like this? Early bird registration is now open for 2021 HEALTHCON in Dallas, Texas March 28-31: http://www.healthcon.com/.