Pediatric Coding Alert

Appealing denials may not be easy, but it’s a process that has the power to enhance your practice’s profitability. Additionally, the more individuals who can navigate the appeals process and learn from prior mistakes, the more likely your practice is to steer clear of denials in the future.

To help you get started, we have compiled five tried-and-tested tips for maximizing your appeal’s chances of success.

Appeal Your Denials to Boost Your Practice’s Earnings

If your organization is like most practices, the denial rate is higher than you’d like it to be. In fact, denials have been steadily on the rise since 2016, according to Holly Ridge, BSN, RN, CPC, CPMA, manager of medical necessity and authorization denials for Duke Health in Durham, North Carolina, during AAPC’s HEALTHCON 2022 session, “Medical Necessity Denials — When and How to Appeal.”

Ridge explained that practices who appeal their denials are successful, on average, approximately 40 to 45 percent of the time. This high success rate can translate to a substantial return on investment (ROI) depending on the services your team is appealing.

Tip 1: Submit Adequate Documentation to Show Medical Necessity

A provider must show the medical necessity in the documentation and coding to receive reimbursement for the services performed. Without that crucial information, Medicare or commercial payers won’t authorize payment and may deny the claim. When a denial comes across your desk, you should review the information, include any missing information, and ensure the codes assigned show medical necessity for the procedures.

Example: Sometimes the provider can’t get enough traction to easily remove a patient’s percutaneous endoscopic gastrostomy (PEG) feeding tube during an evaluation and management (E/M) encounter. In this situation, the endoscopy needed would be reported with 43247 (Esophagogastroduodenoscopy,flexible, transoral; with removal of foreign body(s)). Placement of the new gastrostomy tube would be reported with 43246-59 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube; Distinct procedural service) since it did involve endoscopic guidance.

However, without access to notes that state the medical necessity of the endoscopy, most payers would likely deny that claim. Because National Correct Coding Initiative (NCCI) edits state that intubating the gastrointestinal tract includes subsequent removal of the tube, you need to make it clear why the provider had to go above and beyond the standard procedure. This might mean including time spent and any concerns or evidence at the time of pain or injury.

Remember: “There are some medical necessity denials that are going to need an appeal and medical records to support reimbursement, but sometimes your medical necessity denials may be able to be corrected by taking a second look at that coding and see if there are any coding updates you can make,” Ridge says.

Tip 2: Create Templates to Ensure Consistency

“I very strongly recommend having templates. It makes it easier on yourself; it also provides ease of workload,” Ridge said. By having templates available, your staff will be able to plug the necessary information into the appropriate places and ensure each appeal is formatted similarly.

Examples of templates for different types of denials include:

• Authorization denials
• Medicare denials
• Commercial payer denials

“Templates look cleaner, more organized, and can look more professional. Templates can also help provide content reminders to staff as they write their appeals,” Ridge added.

Tip 3: Support Your Case With Available Resources

Before submitting your appeal, you’ll need to defend your reasoning for reimbursement. “You really want to pull in any argument you can find that supports the safety and efficacy of providing the service that you’ve rendered,” Ridge stated.

Types of resources to use in your appeal with examples include:

• Payer policies: Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), commercial payer policies, Medicare Advantage policies
• Nationally recognized criteria: InterQual, Milliman
• State and federal regulations: Affordable Care Act (ACA), state definition of medical necessity, Emergency Medical Treatment and Active Labor Act (EMTALA), state laws
• Society guidelines/medical literature: American Academy of Pediatrics (AAP), Federation of Pediatric Organizations (FOPO), American Pediatric Society (APS), AMA, National Comprehensive Cancer Network (NCCN)
• Miscellaneous: National Correct Coding Initiative (NCCI) guidelines, peer-reviewed journals, extenuating circumstances

As you compile the different resources available to back up your appeal, you may need to consider the various costs of information. Some nationally recognized criteria may require a subscription fee, but medical literature and medical society guidelines could be available free of charge.

“[Medical literature and society guidelines] are free, they’re very reputable, they’re widely accepted as the standard of care, and they’re accessible,” Ridge said.

Tip 4: Keep the Appeal Window Timeframe in Mind

When a claim is denied, you’ll have a certain timeframe in which you can appeal the denial. This appeal window may be between 60 and 180 days, or it could be as short as 30 days. The appeal window timeframe varies by payer, so it’s crucial to examine the information you receive with the denial as well as the individual payer’s preferences or your contract terms.

Work queues may allow you to use a type of scoring to prioritize payers with a short appeal window. However, if you work manually, you’ll want to educate your staff on which payers have shorter appeal windows, so your staff doesn’t miss the deadline.

Tip 5: Review Why Claims Are Receiving Denials

One of the easiest ways to reduce your denials is by preventing them from the start. This can be done by analyzing your denial data. When you examine your data, you may find denials that could have been avoided and prevented by making minor changes before the claims were submitted.

At the same time, your analysis could show which types of appeals were successful and which denied services payers approved after a successful appeal. In those instances, you should continue to appeal those denials.

Plus, by analyzing your denials, you can focus on what to prioritize during appeals, as well as what improvements your practice can make on the front end through education, proper coding, and documentation to reduce the number of denials you receive.