Medicare Compliance & Reimbursement

Hint: Review code guidelines to back up claims.

If Medicare denials are piling up at your practice, you may want to figure out why.

Medicare billing is complicated, but that doesn’t mean you can’t fix your denial woes. During an American Academy of Professional Coders’ Healthcon meeting last year, Maggie Fortin, senior manager at Baker Newman Noyes, outlined some common reasons for denials, where they happen, and how to stop them at your office. Take a look at some of the top reasons your claims may be denied:

Payer problems: If your claim fails to identify the correct payer who’s liable for the services rendered — like worker’s comp or Medicare secondary payer, for example — then CMS may deny your submission.

• Look for: Reason code 22.
• Look at: Patient Access and Registration.

Missing modifier: If you bill Medicare for an E/M service reported with a procedure, but forget to append modifier 25, you should expect a denial.

• Look for: Reason code 4.
• Look at: HIM/coding.

Tip: “Look at the chargemaster or charge capture processes,” suggests Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG Inc. in Raleigh, North Carolina. “Sometimes modifiers are hard-coded in the CDM and/or appended/selected by ancillary department staff,” Goodman adds.

Incomplete submissions: If your claims are missing information, a denial may be forthcoming. In fact, insufficient documentation accounted for 64.1 percent of last year’s improper payment rate for Medicare, according to CMS’s Comprehensive Error Rate Testing (CERT) data.

• Look for: Reason code 16.
• Look at: HIM/coding.

Tip: You might also check Patient Financial Services, says Goodman. Sometimes missing codes may originate from incorrect file maintenance.

Two services, same date: You may receive a denial if the payer bundles a service you performed into another service. Many claims are denied because insurers deem the payment for them as included in the more significant service.

• Look for: Reason code 236.
• Look at: HIM/coding, NCCI edits.

Determination debacles: If the diagnosis your practice reported did not meet LCD/NCD guidelines, your MAC will probably send it back.

• Look for: Reason code 50.
• Look at: Clinical documentation and/or HIM/coding.

Duplicate billing: If your claim looks like a duplicate bill, perhaps due to a forgotten modifier, then you can be assured that your MAC will deny it.

• Look for: Reason code 18.
• Look at: Patient Financial Services. Billing system may be failing to detect duplicate claims.