Gastroenterology Coding Alert

Follow Medicare's rules for faster appeals processing

Making sure your claims are flawless every time doesn't always mean you-ll prevent denials. Use these checklists to get all the money you deserve when you know Medicare should pay the claim.

Remember: You don't have to appeal a denial if you find you-ve just made a mistake on the denied claim, according to CMS. Just ask your carrier to reopen the claim so you can correct the error.

When submitting an appeal at the first level, you should use form CMS-20027, which you can download at www.cms.hhs.gov/forms. If you choose not to use the form, your written request must include:

- the patient's name
- the Medicare Health Insurance Claim (HIC) number
- the specific service and/or item(s) for which you-re appealing
- the specific date(s) of service
- the physician's name and signature or that of her   authorized or appointed representative.

And regardless of whether you choose to use CMS- form, you should attach any supporting documentation to your appeal request.

Checklist #1: Is There an Error?

If you receive a denied or underpaid claim, you first have to make sure that the denial isn't a result of the way you filed the claim. To do so, follow these steps as outlined by Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Shrewsbury, N.J.:
 
1. Read denial codes on explanation of benefits (EOB) to determine the payer's reason for denial or underpayment.
2. Audit and review coding documentation.
3. Make sure the documentation supports what was billed.
4. Determine that the payer made an error.

Once you-ve determined that Medicare made an error, you can write a letter expressing why you think your carrier should pay the claim. Just remember that Medicare requires that you file your request within 120 days of the date of the notice of initial determination. Check with private payers to find out their time limits.

An example: Your physician performs a level-four  inpatient consult on a patient for gastrointestinal bleeding. During the exam, the physician decides he needs to perform a colonoscopy to determine the bleeding source. During the colonoscopy, the physician finds an actively oozing arteriovenous malformation (AVM) and uses an argon plasma coagulator (APC) to stop the bleeding. The billing office submits the charges for this date of service as 99254 (Initial inpatient consultation for a new or established patient ...) with 578.1 (Blood in stool), and 45382 (Colonoscopy ... with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) with 569.85 (Angiodysplasia of intestine with hemorrhage).

When the carrier pays the claim, it bundles the consult code (99254) with the procedure (45382) because the coder did not place modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the consult. This bundling edit can be corrected by adding modifier 25. In some cases, it can even be handled over the phone.

Checklist #2: Use the Correct Style

Medicare prefers that you follow certain guidelines when you write appeal letters, so start off on the right foot by writing your letter correctly. Medicare needs to handle these letters as quickly and efficiently as possible, so correct style will help the reviewer focus on your appeal rather than getting tripped up on your style.

Be sure to use the following guidelines:

- Keep the language simple.
- Do not use abbreviations or jargon.
- Write in a positive, not negative, tone. Avoid words or phrases that emphasize what cannot be done.
- Avoid one-sentence paragraphs and uneven spacing  between paragraphs.

Checklist #3: Format Your Letter Correctly

Like correct style, correct formatting allows the reviewer to get to the heart of your letter--your appeal--more easily:

- Don't use numerical dates. For example, use April 20, 2006, instead of 4/20/06.
- Use a font size of at least 12 points and stick with the Universal or Times New Roman fonts.
- Use bullet points to clarify lengthy or complicated subject matter.
- Use headings to break up a long letter. For example, headings like -Decision,- -Background- and -Rationale- are acceptable.
- Associate the code with the procedure name when citing procedure codes.
- Don't use span dates for one day of service.
- Avoid using all capital letters because it makes your letter appear impersonal and computer-generated.

Checklist #4: Structure Your Letter Correctly

Now that you-ve determined that you have a denial to appeal and set up your style and formatting correctly, you should focus on the content.

Make sure you include the following information in your appeal letter:

- Include a contact person and her phone and fax numbers
- Explain what Medicare didn't pay or underpaid
- Explain why the coding was correct and why the carrier should have paid the claim
- Explain what rule you based the appeal on
- Include any documentation to support your point, including coding information from books, rules and regulations as set by federal and state government and from local carriers.

Find out more: You can find more information on the Medicare appeals process at www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf. To receive a sample appeals letter, e-mail the editor at teenaa@elijournals.com.