Neurosurgery Coding Alert

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 a man who injured his back lifting a box at work, look back at your notes. Maybe you should have billed workers compensation first.

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

Or, if Medicare pays only part of the claim for a brain tumor patient, for example, 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: Confirm Reason for Denial

After youve checked your records and youre sure your office handled the claim properly, you should call the insurers claims department and find out the reason for denial, says Mazzocco. A denial code may explain exactly what to do, such as adding a fifth digit to an
ICD-9 code. But, if a coded denial explanation does not provide enough detail, Mazzocco urges coders to call the insurer and find out exactly why it rejected the claim and what the insurer needs from you to correct the denial.

Note: Some carriers will let you appeal the matter over the telephone, in which case it is settled. But, any such rulings should be followed up by written documentation from the carrier.

Step Four: Put Your Appeal In Writing

Mazzocco recommends that if a corrected claim does not solve the problem, practices should document any subsequent conversations with the insurer in a letter, along with any supporting documentation the insurer may request. If, for example, the insurer needs proof that the reexploration diskectomy (63042) and the initial diskectomy (63030) were performed on two different levels, the letter should read, Referencing my conversation with your claims representative, Mary Smith, on April 20, 2000, regarding claim #0000000, 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 recurrence of a herniated disk (722.7) resulting in the nerve once again experiencing compression; and

Operative report from the March 21, 2000 surgery, where the re-exploration microdiskectomy was performed on level L4-5 and the initial diskectomy was performed on level L5S1.

Note: This should include an explanation regarding the complexity of the reexploration that needed to be performed to validate the reason for payment.

By inclusion of this information, we are requesting that you pay for both the reexploration and the initial exploration. Thank you for your review of this claim.

You should never just copy the chart/operative report and send that with your appeal letter because if the insurer is looking for specific information, it doesnt want to waste time sifting through the entire chart to find the documentation its seeking. You have a better chance of getting a positive response if you give the insurer exactly what it needs, says Mazzocco.

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. This wastes time on both sides.

Step Five: Assess Denials for Specific Procedures

Keep tabs on the number of denials and the types of denials youre receiving from your insurers, says Mazzocco. 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 type of claims.

We find that many times, providers do not update their systems, so they dont have an appropriate understanding of the current coding. If youre getting the same denial on a particular number of claims with the same insurance carrier, you should gather all of those claims and request a meeting with the provider relations representatives at the insurance carrier to determine the cause, says Fleischman.

Practices also should capture any denial codes at the time of posting, and print out monthly reports either totalling by denial code or ordering the denied charge reports by denial code or patient alpha 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, which you believe is in accordance with CPT coding requirements, and get the carriers feedback of why its denying it, says Fleischman. If the practice handles an appeal in the way the contract specifies and they still get denied, a physician representative of the practice and the administrator or billing manager should write a letter to the insurers medical director requesting a meeting to determine the cause of the rejections.

Should You 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, a 1,000-bed facility in Royal Oak, Mich., explains, Appealing denials is usually based on volumes or money involved. I would never try and appeal anything worth 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.

Every time your practice receives a denial, you should review the claim, says Mazzocco. This will at least give you the appropriate information about what went wrong and help you decide what steps need to be taken to recover denied claim money.