Neurology & Pain Management Coding Alert

Tired of filing appeals that go nowhere? Check out these five tried-and-tested tips to give your appeal every chance to succeed.

Tip 1: Show Medical Necessity With Correct Codes

A provider must show the medical necessity in the coding and documentation to receive reimbursement for the services performed. Without that crucial information, Medicare or commercial payers won’t authorize payment and may deny the claim. When a denial comes across your desk, you should review the information, include any missing information, and ensure the codes assigned demonstrate why the service or procedure was medically necessary.

Remember: If the error is a simple matter, such as using a truncated diagnosis code when the record provides adequate medical information for a complete code, you can make that change yourself. However, some medical necessity denials will require additional information from the provider before you can file an appeal.

Tip 2: Use Templates for Consistency

“I very strongly recommend having templates … to ease [your] workload,” Ridge said. By having templates available, your staff will be able to plug the necessary information into the appropriate places and ensure each appeal is formatted similarly.

Examples of templates for different types of denials include:

• Authorization denials
• Medicare denials
• Commercial payer denials

“Templates look cleaner, more organized, and can look more professional. Templates can also help provide content reminders to staff as they write their appeals,” Ridge added.

“Many electronic billing systems now include templates. Take advantage of these and have them prepopulated before they are needed,” advises Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager at MRO in Philadelphia.

Tip 3: Use Resources to Back Up Case

Before submitting your appeal, you’ll need to defend your reasoning for reimbursement. “You really want to pull in any argument you can find that supports the … service … rendered,” Ridge stated.

Types of resources to use in your appeal with examples include:

• Payer policies: Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), commercial payer policies, Medicare Advantage policies
• State and federal regulations: Affordable Care Act (ACA), state definition of medical necessity, Emergency Medical Treatment and Active Labor Act (EMTALA), Prudent Layperson Standard, applicable state laws
• Miscellaneous: Society guidelines/medical literature, National Correct Coding Initiative (NCCI) guidelines, peer-reviewed journals, professional organizations

As you compile the different resources available to back up your appeal, you may need to consider the various costs of information. Some nationally recognized criteria may require a subscription fee, but medical literature and medical society guidelines could be available free of charge.

“It is also a good idea to keep the resources to the point and to a minimum. There is such a thing as too much information,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, president of Perfect Office Solutions in Leesburg, Florida.

Tip 4: Know Appeal Window

When a claim is denied, you’ll have a certain timeframe in which you can appeal the denial. This appeal window may be between 60 and 180 days, or it could be as short as 30 days.

The appeal window timeframe varies by payer, so it’s crucial to examine the information you receive with the denial, as well as the individual payer’s preferences or your contract terms.

Work queues may allow you to use a type of scoring to prioritize payers with a short appeal window. However, if you work manually, you’ll want to educate your staff on which payers have shorter appeal windows, so your staff doesn’t miss the deadline.

Hint: “It’s good practice to keep a spreadsheet of open denials with appeals deadlines, or to employ billing system software work-queue functions to manage deadlines,” Joy says.

Tip 5: Discover the Why of the Denial

One of the easiest ways to reduce your denials is by preventing them from the start. This can be done by analyzing your claims data to find denials that could have been avoided and prevented by making minor changes before the claims were submitted.

For instance: A common problem is a timely filing denial, which can happen when you file to the wrong payer, according to Jennifer Swindle, RHIT, CCS, CCS-P, CDIP, CPC, CIC, CPMA, CFPC, CEMC, AAPC Fellow, in a presentation titled “Top Denials and how to work them effectively and prevent them in the future” at AAPC’s 2023 virtual REVCON.

Data: Your analysis of denials could show which types of appeals were successful and which denied services payers approved after a successful appeal. In those instances, you should continue to appeal those denials.

Plus, by analyzing your denials, you can focus on what to prioritize during appeals, as well as what improvements your practice can make on the front end through education, proper coding, and documentation to reduce the number of denials you receive.