Inpatient Facility Coding & Compliance Alert

Use modifiers to your advantage, and more, says Novitas.

If you spend a lot of your valuable time processing appeals for denied claims, it’s time to nail down your problems on the first claim submission itself.

“There are many reasons for claim denials. In general, the biggest issue is that some piece of data or information is missing,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants, Inc., in Ames, IA.

Novitas Solutions, a Part B contractor in 11 states, offers advice, enlightening you on how your practice can avoid appeals. Read on for ten essential tips from this MAC.

1. Confirm that all data pertaining to the service is accurate. Missing just one important element — such as the correct date of service — can cause your claim to enter the denial pile.

2. Familiarize yourself with Local Coverage Determinations (LCDs). CMS defines LCDs as “a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis …” This means that these are often different based on which Part B MAC you’re billing, so keep them handy to see your local rules and regulations for any particular service.

3. Get to know the National Coverage Determinations (NCDs). These directives show you CMS’s national rules on how to report a particular service. Some regulations — such as non-coverage for cosmetic procedures — are universal and don’t vary on a MAC-to-MAC basis.

4. Use modifiers when applicable. Reporting a global code when someone else has already reported the same code with a TC (Technical component) modifier will prompt a denial for you. In these cases, when a modifier such as 26 (Professional component) applies, your appropriate use of it will make or break your claim.

5. Ensure that your documentation of a repeat or duplicate service shows the distinct nature of the two services. If you don’t document them separately — and use the appropriate modifier such as 76 (Repeat procedure or service by same physician or other qualified health care professional)—you’ll be facing denials.

6. Send supporting documentation when you’re using modifiers that require more detail, such as modifier 52. Some LCDs or NCDs will specifically indicate that you must submit additional records if you’re appending modifier 52 (Reduced services) or 22 (Increased procedural services). In these situations, if you submit the code and modifier but fail to send in the documentation, your service will be denied.

7. If the MAC requests documentation, send it immediately. Typically, when MACs ask for more information, they won’t pay you until you send it and they review it. Comply with any record requests promptly to make certain that you don’t slow down reimbursement.

8. Ensure that documentation includes the rendering physician’s signature. Spending that extra minute just to check on the provider’s signature can save you a lot of disappointment later.

9. Describe unlisted procedure codes. Just turning in an unlisted CPT^® code is not enough to collect payment from your MAC. You should submit your claim electronically with a short description of the procedure in the electronic equivalent of box 19 of the CMS-1500 form. Follow up with the paper claim and documentation and include a note stating that you’re sending a “documentation” copy, not a duplicate copy.

10. For Medicare Secondary Payer (MSP) claims, always include information from the primary insurer. The MSP needs to know how much (if any) the primary payer already reimbursed you before processing the claim.

Here’s more: “In specific areas, the problem is often that coding/billing staff are not following all the guidelines such as updated guidance from the NCCI Edit Coding Policy Manual,” tells Abbey. “These guidelines apply to both physicians and hospitals.” So keep yourself updated on all the new changes and stay on track.

Resource: To read Novitas’ complete list of ways to avoid appeals, visit www.novitas-solutions.com/ and click “Appeals.”