ED Coding and Reimbursement Alert

Question: We submitted a claim to our Medicare payer and then realized afterward that it had a CPT® code on it that was missing a number — therefore, our clerical error is going to cause this claim to deny. Should we appeal?

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Answer: You should definitely fix the claim, but instead of launching an appeal, you can instead request a claim reopening to fix your error.

What that means:  Reopening is a process for correcting a minor error or omission on a claim without having to pursue the formal appeals process. This is a completely separate process from Medicare appeals, and you can even request a reopening over the phone or online, in addition to via written request. Keep in mind that your claim will have to be finalized before you can request a reopening, so make sure you confirm via the online claim tracking service that your claim has been finalized before you request one.

During reopening, you can change items such as the charge, the place of service, the quantity billed, the date of service (as long as it’s in the same calendar year), the procedure or diagnosis code, or a patient’s Medicare number.

You can even add a modifier during the reopening process. For instance, if you’re seeking reopening of a claim that is denied as a duplicate, you can add a modifier such as 59 (Distinct procedural service), 76 (Repeat procedure or service by same physician or other qualified health care professional), 77 (Repeat procedure by another physician or other qualified health care professional) or others to confirm that the services are separate and not duplicates.

Keep in mind that reopening isn’t always an option. For instance, you can’t request the addition of a line of service that was not initially billed on the claim, and you can’t use reopening to get paid for ambulance services that are statutorily excluded or for any claims that have already started the appeal process.

Plus, if the change requires additional documentation to be provided in order for the correction to take place, this would be a redetermination issue and would not be processed at the reopening level. Contact your MAC if you require a reopening on a claim.