General Surgery Coding Alert

See if you qualify for low volume appeals settlement.

If you hate appeals but aren't willing to settle for unpaid claims in your general surgery practice, you might have more options at your disposal than you knew.

Depending on the situation, we have five new tips to help you correct erroneous claims and get the pay you deserve while possibly avoiding or simplifying the appeals process.

Tip 1: 'Reopen,' When You Can

If you've submitted a claim and get a rejection due to a simple clerical error, you might be able to "reopen" the claim to fix your error rather than filing an appeal.

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," said NGS Medicare's Gail O'Leary during the Part B MAC's webinar, "The Appeals Process and How to Avoid Appeals."

You can request a reopening online, by phone, or by written request once the claim has been finalized. 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, O'Leary said.

Limitations: You can't use reopening to change the year on a date of service or to change billing provider information. Nor can you use reopening to add a line of service not billed on the initial claim, or for any change that requires additional documentation for a redetermination.

Tip 2: Don't Appeal Unprocessable Claims

If CMS returns your claim as "unprocessable," you don't have to file an appeal to submit a corrected claim.

Here's why: The CMS Claims Processing Manual describes as unprocessable, any claim with incomplete, missing, or invalid required information. If your claim is rejected as unprocessable, "there are no appeal rights on this type of denial, because your claim was never actually processed, so there is nothing to appeal," O'Leary said. "Your only option is to correct your errors and resubmit the claim for processing."

Tip 3: Remember the IRO Option

If you do have a claim you've appealed and you've exhausted the process, you may still have recourse to settle the claim and get paid.

Federal law §147.136 "Internal Claims and Appeals and External Review Processes" says that you have the right to submit claims to an independent review organization (IRO) even after the appeals process is exhausted.

Submitting a claim to IRO is ostensibly less expensive and less of a hassle than litigation for everyone involved, and the opportunity provides some protections for providers. Plus, IROs are inherently neutral, as they have no financial stake or conflict of interest.

Don't forget: IROs are binding, according to Angela Boynton, RHIT, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, principal at Boynton Healthcare Management Solutions LLC in Shrewsbury, Massachusetts. Once a claim has been sent to an IRO, you cannot pursue other avenues.

Tip 4: Avoid Errors From the Start

This tip sounds pretty self-evident, but it bears stating that the best way to minimize appeals is to do it right the first time.

To ensure you don't have to process a reopening or an appeal, verify all data on your claim before you submit it, advised NGS Medicare's Lori Langevin during the webinar.

Make sure you've included the physician's NPI, checked off "assignment" or "non-assignment," entered the place of service's ZIP code, and the correct date. Also double check all CPT^® and ICD-10 codes, and any modifiers needed for the claim.

In addition, when applicable, you'll need to add primary payer data and initial treatment dates. Confirm that all of these items are on your claim and in the correct places before you submit it to the payer, and you can hopefully avoid having to reopen or appeal a claim, Langevin said.

Tip 5: Earn Easier Settlement Option with Few Appeals

If you do everything right and succeed in filing appeals only rarely, you could earn a reward for good behavior if you ever need to make a settlement. CMS now offers an option that may expedite your appeals process - for a price.

"As part of the broader Department of Health & Human Services commitment to improving the Medicare appeals process," CMS will offer an additional settlement option for provider and supplier appellants with appeals pending at the Office of Medicare Hearings and Appeals and the Medicare Appeals Council at the Departmental Appeals Board, the agency says on its "Appeals Settlement Initiatives" website.

"The low volume appeals settlement option (LVA) will be limited to appellants with a low volume of appeals pending at OMHA and the Council," CMS continues.

Just how low? "Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and the Council, combined, as of November 3, 2017, with a total billed amount of $9,000 or less per appeal could potentially be eligible, if certain other conditions are met," according to the website. "CMS will settle eligible appeals at 62 percent of the net allowed amount."