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 ordered later the same day (82374, Carbon dioxide [bicarbonate]), you could appeal if you have the appropriate documentation. Although NCCI bundles 82374 as a component of 80051, you can append modifier -59 (Distinct procedural service) to 82374 and submit documentation showing the later order for the test, indicating that you performed a second carbon dioxide on the same day. 

Keep Up With Appeals

You should track appeals to ensure timely resolution. Carriers and intermediaries must no longer send you a notice acknowledging that they received your appeal request. CMS recommended calling the contractor after a few weeks to make sure it received the redetermination request. CMS is looking into the possibility of indicating receipt of a request in the Common Working File, one official said. QICs will send acknowledgements, and eventually a Web site will allow you to track your cases, CMS said. 

What Do You Have to Lose?

The reason why many claims get denied may surprise you, says Quinten Buechner, MS, MDiv, CPC, CHCO, president of Wisconsin-based ProActive Consultants. A conversation with an assistant director of a Medicare carrier finally shed some light on the rejections process for Buechner. "I mentioned to him that 95 percent of the appeals that I processed to them were paid." So, if the carrier kept losing at fair hearings, why didn't it just "straighten up the rules?" Buechner asked.

The answer: Medicare never sees 93 percent of the services the program rejects in appeal. "Nobody appeals them, nobody sends them back," and so policies remain unchanged, Buechner says.