ED Coding and Reimbursement Alert

Hint: Some codes have prerequisites before you can report them.

Denials happen to every ED, but if the problem seems to have escalated recently at your practice, it may be time to review a few potential reasons.

Part B payer Palmetto GBA recently released several articles profiling the most common reasons for claim denials. We've gone through the issues that the MAC has highlighted as being problematic in 2018 and matched them to services that EDs frequently perform. Read on to see which issues are on auditors' radar screens, and how you can avoid them.

1. Procedure Code Was Invalid on the Date of Service. Naturally, every coder is eager to use new CPT^®  and ICD-10 codes as soon as the word is out that they're valid - but that doesn't mean you can. New ICD-10 codes go into effect on Oct. 1 of each year, while new CPT^® codes kick in on Jan. 1.

Of course, this problem exists in reverse as well - many coders fail to take note of new, deleted, or revised codes, and keep on reporting services the same way they always have, even after changes have gone into effect. Your best bet is to go through the CPT^® and ICD-10 changes every Jan. 1 and Oct. 1, respectively, and update your systems accordingly so you're always reporting valid codes.

2. Reporting A Service Without First Billing Its Prerequisite. Not all CPT^® codes can be billed on their own - some aren't payable unless you first report a qualify service or procedure.

For instance, suppose the ED physician debrides infected skin from a 20 percent of a patient's body surface and reports two units of +11001 (Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof [List separately in addition to code for primary procedure]). This would not be payable, because add-on codes like +11001 cannot be reported without their "parent" code.

In this case, you'd report one unit of 11000 (Debridement of extensive eczematous or infected skin; up to 10% of body surface) followed by one unit of +11001.

3. Reporting Duplicate Services. If you receive a denial, or you don't get a claim adjudicated as quickly as you hoped, that doesn't mean you should submit it again. "In these instances, claims will be denied as exact duplicates of a charge already submitted," Palmetto says on its website.

Instead, if you disagree with the original claim decision, you can file an appeal. If the problem is instead that the claim is slow in being paid, contact your MAC to find out what the holdup might be rather than resubmitting the claim.