ED Coding and Reimbursement Alert

If your organization is like most practices, the denial rate is higher than you’d like it to be. In fact, denials have been steadily on the rise since 2016, according to Holly Ridge, BSN, RN, CPC, CPMA, manager of medical necessity and authorization denials for Duke Health in Durham, North Carolina, during AAPC’s HEALTHCON 2022 session, “Medical Necessity Denials — When and How to Appeal.”

Ridge explained that practices who appeal their denials are successful, on average, approximately 40 to 45 percent of the time. This high success rate can translate to a substantial return on investment (ROI) depending on the services your team is appealing.

Tip 1: Show Medical Necessity With Proper Documentation

A provider must show the medical necessity in the documentation and coding to receive reimbursement for the services performed. Without that crucial information, Medicare or commercial payers won’t authorize payment and may deny the claim. When a denial comes across your desk, you should review the information, include any missing information, and ensure the codes assigned show medical necessity for the procedures.

Remember: “There are some medical necessity denials that are going to need an appeal and medical records to support reimbursement, but sometimes your medical necessity denials may be able to be corrected by taking a second look at that coding and see if there are any coding updates you can make,” Ridge says.

Tip 2: Create Templates for Across-the-Board Consistency

“I very strongly recommend having templates. It makes it easier on yourself; it also provides ease of workload,” Ridge said. By having templates available, your staff will be able to plug the necessary information into the appropriate places and ensure each appeal is formatted similarly.

Examples of templates for different types of denials include:

• Authorization denials
• Medicare denials
• Commercial payer denials

“Templates look cleaner, more organized, and can look more professional. Templates can also help provide content reminders to staff as they write their appeals,” Ridge added.

Tip 3: Bolster Appeal With Available Resources

Before submitting your appeal, you’ll need to defend your reasoning for reimbursement. “You really want to pull in any argument you can find that supports the safety and efficacy of providing the service that you’ve rendered,” Ridge stated.

Types of resources to use in your appeal with examples include:

• Payer policies: Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), commercial payer policies, Medicare Advantage policies
• Nationally recognized criteria: InterQual, Milliman
• State and federal regulations: Affordable Care Act (ACA), state definition of medical necessity, Emergency Medical Treatment and Active Labor Act (EMTALA), Prudent Layperson Standard, applicable state laws
• Society guidelines/medical literature: American College of Emergency Physicians (ACEP), Annals of Emergency Medicine
• Miscellaneous: National Correct Coding Initiative (NCCI) guidelines, peer-reviewed journals, extenuating circumstances

As you compile the different resources available to back up your appeal, you may need to consider the various costs of information. Some nationally recognized criteria may require a subscription fee, but medical literature and medical society guidelines could be available free of charge.

“[Medical literature and society guidelines] may be free, they’re very reputable, they’re widely accepted as the standard of care, and they’re accessible,” Ridge said.

Tip 4: Know Appeal Window Timeframe

When a claim is denied, you’ll have a certain timeframe in which you can appeal the denial. This appeal window may be between 60 and 180 days, or it could be as short as 30 days. The appeal window timeframe varies by payer, so it’s crucial to examine the information you receive with the denial as well as the individual payer’s preferences or your contract terms.

Work queues may allow you to use a type of scoring to prioritize payers with a short appeal window. However, if you work manually, you’ll want to educate your staff on which payers have shorter appeal windows, so your staff doesn’t miss the deadline.

Tip 5: Research Reasons for Denials

One of the easiest ways to reduce your denials is by preventing them from the start. This can be done by analyzing your denial data. When you examine your data, you may find denials that could have been avoided and prevented by making minor changes before the claims were submitted.

At the same time, your analysis could show which types of appeals were successful and which denied services payers approved after a successful appeal. In those instances, you should continue to appeal those denials.

Plus, by analyzing your denials, you can focus on what to prioritize during appeals, as well as what improvements your practice can make on the front end through education, proper coding, and documentation to reduce the number of denials you receive.