Pediatric Coding Alert

During her HEALTHCON 2024 session, “Advanced Appeal Strategies,” Michelle Mesley-Netoskie’s, COPM, COC, CPC, CPB, CPMA, CPPM, CRC, CPC-I, aimed to help medical coders aggressively appeal their denied claims and refused to accept “denial upheld” as an answer.

She reminded coders that “the insurance company is not looking out for you, and they will not give you tips on how to get more money.”

Read on to learn tips and tricks to not only avoid claim denials, but to be more aggressive when filing an appeal in the future.

Review the Denial Reasons to Prevent Future Denials

Teaching staff to review current denial reasons in detail can prevent future denials. “Really understanding what the problem is and how to fix it is half the battle,” said Mesley-Netoskie. Be sure that your staff can scrutinize the denial to verify that

patient coverage was correct, the procedures/diagnoses were coded correctly, and to understand the various medical policies in place. “You may need to go through the claim step-by-step for them starting with the CPT^® definitions and go from there,” said Mesley-Netoskie.

Common denial reasons include:

• Missing prior authorization
• Missing or incorrect insurance
• Incorrect patient date of birth
• Provider network issues
• Patient eligibility
• Duplicate claim submission
• Coordination of benefit errors
• Timely filing deadlines
• Bundled or global service errors

She also warned, “Beware of self-insured plans. When your team is calling for preauthorization, make sure the representative is going all the way into that self-insured policy, so the benefits are correct.” Knowing this information will help your staff understand when it’s appropriate to submit a corrected claim versus when to file an appeal.

Use These Tips and Tools

There are simple steps your staff can take to stay on top of claims that are hung up in the process.

“The claims that get stuck in the clearinghouse are quick money. Someone on staff needs to be checking those daily to get them out the door,” Mesley-Netoskie said. She also advised that if you fix the claim in the clearinghouse, make sure you update that in your system as well, so no one is wasting time on work that has already been completed by another member of your office staff.

Another easy tip that is often overlooked: “Make sure your team’s resources are new and up to date,” said Mesley- Netoskie. It may seem like common sense, but a lot of denials stem from easily preventable problems like using outdated codes and policies. Aside from using current coding books or software, be sure you have an audit sheet or system that your whole staff is familiar with.

Many claims are denied due to medical necessity. To avoid this, be sure that your practitioner’s operative notes accurately describe what was done during the procedure before submitting your claim.

Preauthorization denials are also very common. If your claim is denied because the preauthorization on file no longer covers a procedure because a surgeon changed course mid-procedure, “you can appeal that and point out to the payer that going into the [operating room] OR costs about $8,000, so it would be more wasteful to stop the procedure to wait for a new preauthorization and re-enter the OR at a later date,” she stated.

Be aware of how you notate procedures or visits in your system “You want to change up your notes to make each procedure unique. It’s not good when they pull the records as a whole and they all look the same,” she said. If all of your notes vary slightly, that helps prove that each patient and claim is unique and deserves their review.

Consider These Appeal Suggestions:

• Even if no authorization is needed, check for a medical necessity policy
• Remember to include diagnosis codes and modifiers
• Ask for more details when you see “denial upheld” as a reason code
• Reference any applicable policies in the appeal
• Include an audit sheet
• Include a brief letter from the practitioner clarifying anything unusual
• Ask for a coder or medical director to review the denial

Mesley-Netoskie stated that she includes a note on all of her appeals. For example, she may write, “Please do not respond with ‘denial upheld.’ Please explain why the E/M is global to the unplanned office procedure. In addition, please indicate the level of certification of the person who reviewed this documentation.”

Last Line of Defense

Once you have a denied claim and you are submitting an appeal, “be sure you are providing details the first time, so you aren’t going back and forth during the appeal process,” said Mesley-Netoskie. Giving personal details about why a patient needed a seemingly unnecessary service may be necessary to get your point across. “Really explain to the claims examiner, for example, that the patient is at high risk of __________, which can pose a danger to themselves or others due to __________. The insurance payer needs to hear that sometimes,” she said.

If it’s a planned procedure that was denied, you may need to “change your verbiage to say this is a planned procedure, but as the doctor was walking out the door, the patient mentioned that their ________ is/are still bothering them,” which is why additional services or procedures took place that should still allow payment, she said.

As a last resort, understand that sometimes a member will have more success than a medical office when appealing a Medicare-approved procedure or visit. “If you know there is a procedure that can benefit the patient, you should support and help the patient by giving them medical documentation to help them appeal a decision,” she stated.