Orthopedic Coding Alert

If your appeal letters do nothing more than generate more denials, it may be time to update your letters. Check out the following five tips, and get your appeal letters to work for you.

Tip 1: Know Your Individual Payer Guidelines

Before you begin the appeal process, first check the payer's policies. If, for example, the payer has a policy that bundles range-of-motion testing (95851-95852) into any E/M services performed on the same day and will not be reimbursed separately, don't appeal these. Writing appeals is time-consuming enough, so you don't want to waste time on appeals you cannot win because there is already a specific policy in place. 
 
In your office, you should have a provider manual and, likely, access to the payer's online manuals. Next, be sure you follow their appeal procedure exactly. Often, the address to submit appeals is different than the claims address, and some payers require you to send a special form with the appeal.  

Tip 2: Use Specific Keywords to Include in the Appeal

Rather than sending a generic appeal letter for every denial, customize yours with the appropriate key words for each situation. For instance, suppose you submitted a claim for an E/M service and injection on the same date. On the claim, you appended 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 service code, but the payer still denied it. 
 
Instead of sending a letter stating, -the claim was submitted correctly,- send a letter that addresses the specific claim and the specific reason(s) why modifier 25 was appropriate. Further, you should quote industry guidelines (such as CPT and/or CMS guidelines) and, if available, the insurance company's own guidelines. (See example on page 70.)

Tip 3: Use Templates

Composing appeal letters can be time-consuming. But you can save time by identifying your most common denials and creating fill-in-the-blank appeal letters for each of these scenarios. 
 
For example, you may find that you receive many denials for bundling issues even when you use modifier 59 (Distinct procedural service) properly. Chances are, the letters you compose will start and end basically the same. By creating a base template, you can concentrate on filling in the details for each claim instead of writing each one from scratch. (See example on page 71.)

Tip 4: Include Documentation

To make your appeals work for you, include as much documentation as possible. At times, this may involve looking beyond just the office note for that date of service. For instance, if the provider removed two separate lesions and one is denied, you may want to consider also sending a copy of the pathology report to further strengthen your case. 
 
Another thing to consider is sending copies of CPT Assistant or specialty-society articles (however, check copyright guidelines and ask permission if necessary). The more -ammunition- you have, the better. 

Tip 5: Sometimes a Phone Call Is Better 

If you suddenly start receiving many denials that you never received before from a payer, a phone call may be your quickest way to handle this. Perhaps the payer had a recent policy change you weren't aware of or a software update that caused erroneous denials. Either way, a sudden increase in denials requires immediate attention. 

 -- Erica D. Schwalm, CPC-GSS, CMRS, is a billing and coding educator in Springfield, Mass.