Gastroenterology Coding Alert

Find expert advice on how to structure your appeal letter.

In Gastroenterology Coding Alert volume 26 number 6 , we looked at appealing point of service (POS) denials before care is rendered because “it’s easier to fight the site of care issue before the service is rendered and the denial becomes authorization related,” said Holly Ridge, BSN, RN, CPC, CPMA, manager of medical necessity and authorization denials at Duke University Health System in Durham, North Carolina, during her HEALTHCON 2024 presentation, “The Place of Service Conundrum.” This is because so many payers consider authorization denials as administrative denials, which can be quite difficult to appeal, she said.

This month, we’ll delve a little deeper into pre-billing appeals and guide you through the post-billing appeal process to help you increase your chances of reimbursement.

Combat Potential Denials with Proof of Extenuating Circumstances

There are going to be instances where the provider has a good reason to send a patient to a POS, but the payer needs a little convincing ahead of billing. Note, getting these procedures approved ahead of potential POS or site of service denials will require detailed documentation.

Claustrophobia: For example, the GI doctor may decide to send a patient for magnetic resonance cholangiopancreatography (MRCP) to get a detailed image of the liver and bile ducts. However, the patient is severely claustrophobic.

Some large multispecialty practices may have their own imaging center with an open magnetic resonance imaging (MRI) machine. However, “payers often prefer freestanding clinics because it saves them money ultimately,” explained Ridge. She goes onto say that if your provider orders an MRI, the payer may say they won’t allow it on-site and that the patient has to go to a freestanding clinic. If that happens, you still may be able to bypass the site of care issue before you bill for the procedure by proving the patient’s claustrophobia will be better accommodated at your on-site center.

Pediatric Patient: You may also be able to appeal a potential POS or site of service issue because the patient is a child. “Children are not just smaller adults,” explained Ridge. For example, pediatric endoscopy can be more complex than adult endoscopy because of the smaller size of the child and their organs. This may require specialized equipment and expertise, including anesthesia services, which may not be available in a place other than a hospital setting. The same might go for colonoscopy in some emergency situations.

Pregnancy: Pregnant patients can get colonoscopies, for example, but sedation is needed and must be carefully managed to avoid potential harm to the fetus. This could viably require specialized personnel and equipment best provided in a hospital. Similarly, endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat problems in the liver, bile ducts, and pancreas and is typically avoided during pregnancy. Therefore, if the benefits outweigh the risks (due to radiation), the gastroenterologist may send the patient to a hospital for the procedure. Additionally, “if there’s an emergency, if there is a pregnancy complication and maybe that baby has to unfortunately be delivered early, you want to have the resources to be able to manage that.”

Certain comorbid conditions: There are several conditions a patient can have that can add risk to even routine procedures such as endoscopies. For example, liver disease can complicate most surgeries because of its tendency to cause bleeding disorders and other issues, which makes surgery inherently more risky. Also, patients with cardiac arrhythmia, atrial fibrillation or atrial flutter are at higher risk for complications during surgery. Patients with chronic obstructive pulmonary disease (COPD) are at greater risk during any surgery that will require anesthesia or intubation. Some high-risk procedures/ high-risk patients will foreseeably require an overnight stay at the hospital post-procedure, and depending on the payer, these may be observation services or inpatient. When anticipated, it is certainly best to get coverage ahead of time.

Manage Post-Bill Appeals

If you did not or could not get ahead of the game and avoid the denial before billing, you may still have a shot at reimbursement. The first thing to do is figure out whether you actually do have a shot. For instance, you always want to appeal if there are extenuating circumstance such as any listed in the section above.

Know payer policies: Look up the applicable payer policies and see if you notice any contradictions between the policies and the denials.

Check state and federal regulations: What’s your state’s definition of medical necessity? Almost all states have their own definition of medical necessity, which you might be able to use in a POS appeal.

Reference recent updates: Often, the person who rejects the claim isn’t up to date on recent changes. If that seems to be the case, simply reference the change. Include a link to an online version of the update, if possible. At the very least, include as much information as you can to help direct the payer to the correct literature.

Consider using templates: Use templates with the appropriate legal language so that you or your staff can just pull the template, plug in the patient information, and get it out the door

Plan your appeal: It may seem obvious, but you need to have all the above information organized before you officially appeal. Review any applicable medical policies, authorization history and requirements and billing rules. Also, consider all the denials and responses from the payer so you can reference them in your argument if necessary. Review any pertinent references, and be sure to also complete any required forms.

Effectively Structure Your Appeal Letter

A well-structured letter is always going to work in your favor. Of course, the information has to be accurate, and you can’t win an appeal with structure alone. However, it’s important to make your points clear, concise, persuasive, and professionally. Note that it’s also imperative you attach relevant documentation.

Your letter should have the following components:

Header: Your header will generally include payer contact information, patient demographics, member ID, claim number, and the service that was denied

Body: The body of the letter will include the addressee, a brief intro paragraph, the patient history, your argument, and a brief closing paragraph.

Closing: The closing needs to include a salutation, your name and credentials, and your contact information.