Appeal Denials! Follow Five Steps When Appealing Denials and Receive the Reimbursement You Deserve
Published on Wed Nov 01, 2000
Insurance denials for services ethically claimed are an irritating and frequent occurrence for neurosurgical practices. Many practices spend hours each week appealing these claims. Coders who track common denials and speak directly with claims managers will make better use of their time and gain denied monies than those who send standard appeal letters with a copy of the patients chart.
For example, many coders say they face frequent denials when billing for 63030 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facectetomy, foraminotomy and/or excision of herniated intervetebral disk; one interspace, lumbar [including open or endoscopically-assisted approach]) at level L4-5 (unilateral) and 63042 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facectetomy, foraminotomy and/or excision of herniated intervetebral disk, reexploration; lumbar) at level L5S1 (unilateral), despite the fact that they were performed at different levels.
Note: Modifier -59 (distinct procedural service) also could be used when billing 63030 to prevent this denial and would appropriately be used in the appeal.
The following five tips will help 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 specifically the method for appealing claims. The appeal process may be different for each carrier, and it should be included in the provider manual. The problem starts when practices dont read the contract and dont know how to proceed when they receive a denial.
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 (although there may be some rights to sue under civil law).
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 resubmitting it so they know to offset any amount previously paid.
Step Two: Ensure Accuracy on Your Side
Many denials stem from errors within the 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 a forgotten modifier can result in a denial. Coders should review the patient information before starting an appeal.
Mazzocco suggests that practices review patient information to ensure that 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 [...]
