Neurology & Pain Management Coding Alert

Question: Recently, our claims for multiple nerve conduction studies have been rejected even though we have coded correctly. What are our options for appealing a claim?

Michigan Subscriber

Answer: There are four "levels" of appeal, says 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.

At the first level, or "review," the neurologist asks the carrier if the claim was processed correctly according to the carrier's guidelines. If the carrier says that it was, and refuses to pay, the neurologist may move on to the second level of appeal.

The second level is called "fair hearing," during which the neurologist asks the carrier to take a closer look at its guidelines to ensure that they are correct and were developed fairly. For example, if codes are bundled, the physician may question where the bundling edit originated. If the edit is not contained in the national Correct Coding Initiative (CCI), there may be a greater chance of a carrier medical director ruling in the neurologist's favor.

The third level is the administrative lower-judge appeal. The neurologist appears before a judge, is sworn in and gives evidence. The judge has discretion to determine if the policies being applied are appropriate. An outside medical expert who doesn't necessarily work for the carrier may also testify.

The fourth level is the appeals council. If the appeals council sees that some error was made at the administrative lower-judge level, they will not make a decision. Instead, the appeals council will remand the matter back to the administrative lower judge for a reappraisal. Note, however, that appeals are rarely taken to this level.

Because an appeal must be made on each individual claim, repeated appeals can be time- and cost-prohibitive especially if the claims reach a level-three or higher appeal. If a carrier enforces policies that you believe are unfair, you may also consider contacting the state or national neurological associations to lodge a complaint and learn if other neurologists are facing similar problems with the carrier on a state or nationwide level. And you may file a complaint with your state's insurance bureau.