General Surgery Coding Alert

Common denial reasons include:

• Missing prior authorization
• Missing or incorrect insurance
• Incorrect patient date of birth
• Provider network issues
• Patient eligibility
• Duplicate claim submission
• Coordination of benefit errors
• Timely filing deadlines
• Bundled or global service errors

She also warned, “Beware of self-insured plans. When your team is calling for preauthorization, make sure the representative is going all the way into that self-insured policy, so the benefits are correct.” Knowing this information will help your staff understand when it’s appropriate to submit a corrected claim versus when to file an appeal.

Use These Tips and Tools

There are simple steps your staff can take to stay on top of claims that are hung up in the process.

“The claims that get stuck in the clearinghouse are quick money. Someone on staff needs to be checking those daily to get them out the door,” Mesley-Netoskie said. She also advised that if you fix the claim in the clearinghouse, make sure you update that in your system as well, so no one is wasting time on work that has already been completed by another member of your office staff.

Another easy tip that is often overlooked: “Make sure your team’s resources are new and up to date,” said Mesley- Netoskie. It may seem like common sense, but a lot of denials stem from easily preventable problems like using outdated codes and policies. Aside from using current coding books or software, be sure you have an audit sheet or system that your whole staff is familiar with.

Many claims are denied due to medical necessity. To avoid this, be sure that your practitioner’s operative notes accurately describe what was done during the procedure before submitting your claim.

Preauthorization denials are also very common. If your claim is denied because the preauthorization on file no longer covers a procedure because a surgeon changed course mid-procedure, “you can appeal that and point out to the payer that going into the [operating room] OR costs about $8,000, so it would be more wasteful to stop the procedure to wait for a new preauthorization and re-enter the OR at a later date,” Mesley-Netoskie stated.

Be aware of how you notate procedures or visits in your system. “You want to change up your notes to make each procedure unique. It’s not good when they pull the records as a whole and they all look the same,” she said. If all of your notes vary slightly, that helps prove that each patient and claim is unique and deserves their review.

Consider These Appeal Suggestions

There are a few actions you can take to help keep your appeals to a minimum. They include the following:

• Check for a medical necessity policy — even if no authorization is needed.
• Remember to include diagnosis codes and modifiers.
• Ask for more details when you see “denial upheld” as a reason code.
• Reference any applicable policies in the appeal.
• Include an audit sheet.
• Include a brief letter from the practitioner clarifying anything unusual.
• Ask for a coder or medical director to review the denial.

Mesley-Netoskie stated she includes a note on all of her appeals. For example, she may write, “Please do not respond with ‘denial upheld.’ Please explain why the E/M is global to the unplanned office procedure. In addition, please indicate the level of certification of the person who reviewed this documentation.”

Last Line of Defense

Once you have a denied claim and you are submitting an appeal, “be sure you are providing details the first time, so you aren’t going back and forth during the appeal process,” said Mesley-Netoskie. Giving personal details about why a patient needed a seemingly unnecessary service may be necessary to get your point across. “Really explain to the claim’s examiner, for example, that the patient is at high risk of __________, which can pose a danger to themselves or others due to __________. The insurance payer needs to hear that sometimes,” she said.

If it’s a planned procedure that was denied, you may need to “change your verbiage to say this is a planned procedure, but as the doctor was walking out the door, the patient mentioned that their ________ is/are still bothering them,” which is why additional services or procedures took place that should still allow payment, she said.

As a last resort, understand that sometimes an insurance plan member will have more success than a medical office when appealing a Medicare-approved procedure or visit. “If you know there is a procedure that can benefit the patient, you should support and help the patient by giving them medical documentation to help them appeal a decision,” she stated.