Pathology/Lab Coding Alert

Prepare now for quicker appeals turnaround Now's the time to streamline your lab's appeals process - Medicare is tightening deadlines that will make responding quickly and completely to claims denials more important than ever before.

The timeframe to submit your second-level appeal to the Qualified Independent Contractor (QIC) will shorten to 180 days as of Jan. 1, 2006.

And you'll only have one chance to get appeals right. If you don't include all the important information in your appeal to the QIC, you won't be able to add any more information except if there is "good cause."

That's why you need to follow our experts' advice to improve you claims appeals process. Respond Appropriately to Denials Use all available resources to figure out why the payer denied your claim - that way, you can craft an effective appeal. The explanation of benefits (EOB) form represents the communication between payer and physician and details why insurance denied your claim. There are many reasons for denials - for example, an uncovered service, a bundled service, or an unrecognized modifier. Check your EOBs for the reason for denial to facilitate appropriate follow-up.

Starting in January, when a Medicare carrier rejects your first-level appeal, the carrier will also issue a helpful new notice.

These notices will include specific reasons for the denial and an account of missing information or documentation required for the reconsideration at the QIC level, Jennifer Frantz with the Centers for Medicare & Medicaid Services revealed at the April 15 Open-Door Forum on the new appeals process.

You can read more about Medicare's new appeals process at http://www.cms.hhs.gov/appeals/factsheet.pdf. Document Appeals Completely With the shortening deadlines, you'll have to make sure your appeals have complete documentation the first time around, including all substantiating evidence, says Barbara Cobuzzi, MBA, CPC,CPC-H,  president of Cash Flow Solutions in Cherry Hill, N.J.

Appeals should always include supporting documentation for your coding and billing choices, along with information from outside sources that back up your claim. Insurers are more likely to consider appeals evidence from sources such as the CPT manual , the ICD-9 manual, CPT Assistant, Coder's Desk Reference, National Correct Coding Initiative edits, Medicare manuals, and national specialty societies such as the College of American Pathologists (CAP) and Clinical Laboratory Management Association (CLMA).

Use specific cases as examples, but deal with the encompassing issue - bundling, modifier use, etc. - so you won't be denied on the service again.

Example: If Medicare denies a claim for 80051 (Electrolyte panel) billed with a carbon dioxide test [...]