General Surgery Coding Alert

Question: After checking to be sure we haven't made a coding or billing entry error, our practice automatically appeals payer denials using a standard letter. We don't seem to be very successful in ultimately getting payment. How can we improve our appeals process?

Texas Subscriber

Answer: Successful appeals depend on knowing coverage rules and providing specific information to make your case. Form letters don't address either of those advantages, so follow these tips to get better appeals results.

Check policies: Before you begin the appeal process, first check the payer's policies. If you discover that your surgeon performed a procedure that doesn't show medical necessity according to those policies -- due to bundling or frequency rules, for instance -- don't bother to appeal. Writing appeals is time-consuming enough, so you don't want to waste time on appeals you cannot win because there is already a specific policy in place

Submit to procedure: Next, be sure you follow the payer's appeal procedure exactly. Often, the address to submit appeals is different from the claims address, and some payers require you to send a special form with the appeal. Rather than sending a generic appeal letter for every denial, customize yours with the appropriate key words for each situation. For instance, suppose you submitted a claim for an E/M service and injection on the same date. On the claim, you appended modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code, but the payer still denied it.

Get specific: Instead of sending a letter stating "the claim was submitted correctly," send a letter that addresses the specific claim and the specific reason(s) why modifier 25 was appropriate, in this example. Further, you should quote industry guidelines (such as CPT® and/or CMS guidelines) and, if available, the insurance company's own guidelines.

Create a template: Composing appeal letters can be timeconsuming. But you can save time by identifying your most common denials and creating fill-in-the-blank appeal letters for each of these scenarios. For example, you may find that you receive many denials for bundling issues even when you use modifier 59 (Distinct procedural service) properly. Chances are, the letters you compose will start and end basically the same. By creating a base template, you can concentrate on filling in the details for each claim instead of writing each one from scratch.