Otolaryngology Coding Alert

Question: After checking to be sure we haven't made a coding or billing entry error, our practice automatically appeals payer denials using a standard letter. We don't seem to be very successful in ultimately getting payment. How can we improve our appeals process?

Montana Subscriber

Answer: Before you begin the appeal process, first check the payer's policies. Check to see if, for example, the payer has a policy that bundles 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) into any E/M services performed on the same day. If you feel the policy is not appropriate given the situation specified in the claim (like, the ENT sees the patient for a sinus infection at the time of the impacted cerumen removal, which is a separate problem), you should appeal and fight the payer.

Be sure you follow the payer's appeal procedure exactly. Often, the address to submit appeals to is different from the claims address, and some payers require you to send a special form with the appeal.

Get specific: 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 endoscopy 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 that just states, "the claim was submitted correctly, please pay," send a letter that addresses the specific claim and the specific reason(s) why modifier 25 was appropriate. Address the reasons why the E/M service was significant and separately identifiable, show the different diagnoses if they are present and if not, demonstrate how the E/M service prompted the decision to perform the endoscopy. Further, you should quote industry guidelines (such as CPT^®  and/or CMS guidelines) and, if available, the insurance company's own guidelines.

Tip: 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.