Pulmonology Coding Alert

You may not need a full appeal in this instance, MAC staffers advise.

It’s a common situation — you submit a claim with great confidence that it will be approved and paid, only to find that you made a simple clerical error that caused your claim to be rejected. Instead of launching an appeal, you can instead request a claim reopening to fix your error.

What that means: “Reopening is a process for correcting a minor error or omission on a claim without having to pursue the formal appeals process,” said NGS Medicare’s Gail O’Leary during the Part B MAC’s May 31, 2017 webinar, “The Appeals Process and How to Avoid Appeals.”

Reopening is “a completely separate process from Medicare appeals,” and you can even request a reopening over the phone or online, in addition to via written request, O’Leary said. Keep in mind that your claim will have to be finalized before you can request a reopening, so make sure you confirm via the online claim tracking service that your claim has been finalized before you request one, she added.

During reopening, you can change items such as the charge, the place of service, the quantity billed, the date of service (as long as it’s in the same calendar year), the procedure or diagnosis code, or a patient’s Medicare number.

You can even add a modifier during the reopening process. For instance, if you’re seeking reopening of a claim that is denied as a duplicate, you can add a modifier such as 59 (Distinct procedural service), 76 (Repeat procedure or service by same physician or other qualified health care professional), 77 (Repeat procedure by another physician or other qualified health care professional) or others to confirm that the services are separate and not duplicates, O’Leary said.

Not All Claims Can Be Reopened

Keep in mind that reopening isn’t always an option, O’Leary said. For instance, you can’t request the addition of a line of service that was not initially billedon the claim, and you can’t use reopening to get paid for ambulance services that are statutorily excluded or for any claims that have already started the appeal process.

Plus, “If the change requires additional documentation to be provided in order for the correction to take place, this would be a redetermination issue and would not be processed at the reopening level,” O’Leary said.

The reopening unit does not handle claims that were rejected as unprocessable, and you can’t use reopening to change the year on a date of service, she added. In addition, you can’t reopen claims that require the review of clinical documentation, and you can’t use reopening to change the billing provider information, she said.

Unprocessable Claims Don’t Count

If a claim is deemed unprocessable, the reopening unit won’t be able to handle it. “The CMS Internet-only Manual describes an unprocessable claim as any claim with incomplete or missing required information or any claim that contains complete and necessary information; however, the information provided is invalid,” O’Leary said. “Such information may either be required for all claims or required conditionally.”

If your claim is rejected, “there are no appeal rights on this type of denial, because your claim was never actually processed, so there is nothing to appeal,” O’Leary said. “Your only option is to correct your errors and resubmit the claim for processing.”

Avoid Appeals, Reopenings With These Tips

To ensure you don’t have to process a reopening or appeal, verify all data on your claim, including the physician’s NPI, whether you’ve checked off “assignment” or “non-assignment,” the place of service’s zip code, all CPT^® and ICD-10 codes, the date, and modifiers, said NGS’ Lori Langevin during the webinar. In addition, when applicable, you’ll need to add primary payer data and initial treatment dates (in cases of podiatry, physical therapy, and chiropractic services).

Confirm that all of these items are on your claim and in the correct places before you submit your claim to each payer, and you can hopefully avoid having to reopen or appeal a claim, Langevin said.