Radiology Coding Alert

Do your homework to defend your reimbursement reasoning.

You can significantly increase your practice’s bottom line by winning appeals. Learn five practice-proven tips for giving your appeal its best shot, so you’re ready to act if your practice receives a denial.

Appeal Your Denials to Boost Your Practice’s Earnings

“Denials are rising. Since 2016, the average denial rate was 9 percent and as of the second quarter of 2020, it had risen to 10.8 percent,” said 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 even though the denial rates are increasing, 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: Use Correct Codes 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: A 67-year-old male patient with a family history of abdominal aortic aneurysms (AAA) visits your radiology clinic for an ultrasound screening for AAA. The patient also smoked a pack a day for approximately 20 years, but no longer smokes tobacco. The radiologist who performed the exam interpreted the results and listed an abdominal aortic aneurysm without rupture under the findings. On the report, the coder assigned the following codes:

• CPT^®: 76706 (Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA))
• ICD-10-CM: I71.4 (Abdominal aortic aneurysm, without rupture, unspecified)

While the claim listed the radiologist’s finding as the first-listed diagnosis, the patient’s insurance denied the claim because the claim didn’t show medical necessity for the AAA screening. By revising the claim to include Z82.49 (Family history of ischemic heart disease and other diseases of the circulatory system) and Z87.891 (Personal history of nicotine dependence), you’re showing the patient’s family history of AAA and his previous smoking habit.

“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: AMA, American Lung Association, National Comprehensive Cancer Network (NCCN)
• Miscellaneous: NCCN guidelines, peer-reviewed journals, extenuating circumstances

As you compare the different resources available to back up your appeal, you may need to consider 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.

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 denials data. When you examine your data, you may find denials that were avoidable and preventable by making minor changes before the claims were originally 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.