Pain Management Coding Alert

Question: We were a solo practice for about 15 years, and the founding physician’s wife was the office manager. Her policy was to write off any balance of $30 or below. When she retired and we hired additional staff members, we started to evaluate that strategy, but are now thinking it may be smart to appeal those claims. Can you give us a quick rundown on the basics of appealing to the payers?

Florida Subscriber

Answer: Every practice should create its own policy on when appeals are warranted, but your office should consider establishing a denial management process. If you do choose to work the appeals, keep these four tips in mind:

1. Cite the claim you’re appealing.  It may seem obvious, but claim reviewers report that one of the most common reasons that your appeal could be bounced back to you is if you submit it without referencing the original claim you’re trying to appeal.

2. Draft a clear argument. Spend time creating a refined, strongly-worded, educated, and well-crafted appeal rather than submitting a canned appeal letter that’s entirely from a template.

3. Support your case with regulatory or clinical facts. To bolster your chances of winning an appeal, you should cite facts from factual documents, such as Medicare local coverage determinations (LCDs), CPT^®  Assistant articles, or AHA Coding Clinic articles. You can also include clinical data from peer-reviewed journals or articles from a specialty organization, among other documents. In addition, make sure you cite compliance or regulatory rules when warranted.

4. File appeals on time. Every payer in the country has a limit for filing appeals, so keep careful note of when your appeals are due at each level and make sure you meet those deadlines. Don’t be late, not even by a day.

Documentation is essential: You know that maintaining documentation of patient visits is essential, but many practices don’t maintain strong documentation during the denial and processes. This can be a mistake – you should be documenting every single contact you have with the payer. Record names, dates, times, and synopses of the conversations. Treat every appeal as having the opportunity to land in front of a judge.

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