Neurology & Pain Management Coding Alert

Insurance denials for services provided are a frequent occurrence for neurology practices, many of which spend hours each week appealing these claims.

For example, practices that track common denials and speak directly with claims managers will most likely make better use of their time and gain denied monies than those who send standard appeal letters with a copy of the patient chart.

A recent survey of Neurology Coding Alert subscribers indicates that frequent denials occur when billing for 95900 (nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) and/or 95903 (with F-wave study) on a consistent basis whenever they are reported together for the same patient, even if the studies were performed on different nerves.

The following tips should help neurology practices deal more effectively with appeals:

Step One: Know Your Insurers Appeals Method

According to L. Michael Fleischman, CPC, principal of Gates, Moore & Company, a healthcare consulting firm in Atlanta, many practices arent familiar with their insurers appeals guidelines. The insurance companys provider manual should spell out very specifically what the method is for appealing claims. The appeal process may be different for each carrier, and should appear in the provider manual.

Some independent payers have shorter time limits (60 days) to file an appeal than Medicare (six months). All non-Medicare carriers follow a more informal appeal process than Medicare because none have an administrative law judge level of appeal.

Sometimes it is sufficient to correct the coding and resubmit the claim, saving time and effort. Some carriers want corrected claim written in red in the upper right corner of the HCFA-1500 form before resubmission so they know to offset any amount previously paid.

Step Two: Ensuring Accuracy on Your Side

Many denials can stem from errors within your own practice, says William J. Mazzocco Jr., PA-C, RN, president of Medical Administrative Support Services, a healthcare consulting firm in Altoona, Pa. Simple things like forgetting a modifier can result in denial, so its important to review the patient information in your office before you begin any appeal process.

For example, a neurologist performs a new patient office visit (99201-99205) and decides to perform a lumbar puncture (62270) on the patient on the same date of service. When billing, if the neurologist forgets to attach 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 code, the E/M would not be reimbursed.

Mazzocco suggests that practices review patient information to ensure that facts such as procedure codes, diagnosis codes and modifiers are correct, and that the claim was sent to the correct insurer. For example, if Medicare denies a claim for a patient with carpal tunnel syndrome (354.0), instead of appealing, look back at your notes. You may realize that the claim should have been sent to workers compensation first.

Also, the reason for the denial should be reflected in the Medicare denial code, making it easier to track. A complete list of denial codes should be available upon request from your Medicare carrier.

If Medicare, for example, pays only part of the claim for an epilepsy (345) patient, you may realize that the patient has other insurance that should be primary to Medicare and billed first. If Medicare is primary, it will pay 80 percent of the allowed amount, and the other insurance company will pay 20 percent. Medicare will not perform a coordination of benefits with other payers.

Step Three: Confirming Reason for Denial

After youve checked your records and youre sure your office handled the claim properly, you should call your insurers claims department directly and find out the reason for the denial, Mazzocco says. A denial code may explain exactly what to do, such as adding a fifth digit to an ICD-9 code.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno and a coder who specializes in neurological procedures, adds that some carriers will let you appeal, and possibly settle the denied claim over the telephone. But, any such rulings should be followed up by written documentation from the carrier.

Step Four: Putting Your Appeal In Writing

Mazzocco recommends that practices document the conversation with the insurer in a letter and include supporting documentation that the insurer requested. If, for example, the insurer needs proof that the nerve conduction studies, 95900 and 95903, were performed on two different nerves, the letter should read:

Referencing my conversation with your claims representative, Mary Smith, on April 20, 2000, regarding Claim #00000, you will note that I have included copies of the following:

notes that the physician wrote during his evaluation of the patient on Jan. 16, 2000, when he diagnosed a patient with reflex sympathetic dystrophy (337.20); and

nerve conduction studies report from Mar. 21, 2000, when the nerve conduction studies with and without F-wave study were performed on different nerves to determine what parts of the extremity were affected.

By inclusion of this information, we are requesting that you pay for both the nerve conduction study with F-wave and without F-wave study. Thank you for your review of this claim.

An additional example is a neurologist performing a bilateral H-reflex study 95935 (H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle). In the letter to the insurance carrier include the following information:

notes that the physician wrote during the evaluation of the patient on Nov. 16, 2000, when patient came in with complaints of numbness or tingling of the skin (782.0);

H-reflex study report from Nov. 30, 2000, when the bilateral H-reflex study was performed to check the nerve responses on both the affected side and the nonaffected side for comparison; and

verify that the correct diagnosis code was used to prove the medical necessity for the testing and make sure that modifier -50 (bilateral procedure) was attached to 95935 to document that the procedure was performed bilaterally.

You should never just copy the chart/study report and send that with your appeal letter, Mazzocco says. If the insurer is looking for specific information, it doesnt want to waste time sifting through the chart to find the documentation.

Mazzocco also advises against sending standard form-type appeal letters for each denial. If you send a generated appeal to them, chances are, theyll send a generated denial back to you.

Step Five: Assessing Mass Denials

Keep tabs on the number of denials and the types of denials youre receiving from your insurers, Mazzocco advises. You dont have to do this perpetually for every patient, but if you do it during a three- to six-month time frame, you might start to see patterns in the types of denials youre receiving. Any patterns in denials should spur you to do two things: First, review your own office procedures to determine if someone is consistently miscoding the procedure and, second, investigate why the insurer is repeatedly denying the same things.

Sandham suggests that practices should also capture any denial codes at the time of posting, and print out monthly reports either totaling by denial code or ordering the denial charge reports by denial code or patient alphabetic order. This will provide an early alert system for claims development and billing problems. Use these reports to show insurers why youre billing the procedure the way you are and get the carriers understanding of why theyre denying it.

When to Give Up

Many practices find that its often not worth their time to appeal denials for small dollar amounts. Barbara Shaub, billing manager at William Beaumont Hospital in Royal Oak, Mich., says, Appealing denials is usually based on volumes or money involved. I would never try to appeal anything less than $100.

Mazzocco agrees. Your practice should establish a dollar amount that you will appeal, usually around $75. But, if you keep track of denials and find that youre continually getting the same rejection for a $40 service, you cant just automatically keep writing it off, because $40 over and over again adds up. This is why it is beneficial to track the total number of denials for a particular denial code youre receiving.