Pulmonology Coding Alert

If youve received denials for bills youve submitted for pulmonary care services with no reason given, it might be due to the Health Care Financing Administrations (HCFA) policy of denying claims that fall into the black box of edits. If you try the same code again after Oct.1, 2000, you may not be denied, or at least youll get an explanation of a denial.

In 1998, according to Carol Pohlig, BSN, RN, CPC, reimbursement analyst at the University of Pennsylvanias Department of Medicine in Philadelphia, HCFA contracted with HBOC McKesson to develop correct coding edits. Part of the agreement was that those edits were proprietary. HCFA knows but doesnt tell. The edits couldnt be disclosed to the carriers, who in turn issued unexplained denials to physicians. This groups contract with HCFA will be ended.

If youve tried codes that seem reasonable to you, and youre not part of the standard correct coding initiative and have received denials with no explanation, try them again for future billings. The elimination of the black box edits do not allow for retrospective reimbursement of past denials, Pohlig says, but under the new policy, denials might go away, unless theyre part of standard correct coding edits. At least youll understand why you are being denied.