Urology Coding Alert

Share your top denial reasons with office staff and watch future denials disappear

If you're not a watchdog for your practice's reasons for denial, you run the risk of overlooking big denial trends that equal major revenue loss.

Effective denial management is one of the biggest keys to controlling your accounts receivable, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky. Because reasons for denial can change as frequently as the weather, it takes a focused coding and billing staff to stay on top of them.

Take control: Many billing experts recommend that you focus your denial management process by keeping a running list of your top-10 denial reasons. This list can serve as your guide to systematically address and fix the causes for denials in your office.

Use these six expert tips to compile the information you need for your top-10 list:

1. Update your list every month. Denial management is an ongoing process, so the top-10 denials one month may not be the same next month. In fact, you may find a problem and then fix it, and then you may see it slowly return. That could be due to new physicians joining your practice, new billing software, coders receiving conflicting information from insurers, or many other factors. Therefore, monthly reports are a must.

2. Focus on total and partial denials. Sometimes insurers will deny a claim and not pay any portion of your charges, but you should also pay close attention to the reasons why some claims come back partially paid or underpaid.

If the insurer discounts your charges excessively, the payer might have taken a higher percentage discount than your contract allows. Or, the payer may have downgraded your E/M or procedure claim (for example, from CPT 99214 to CPT 99213 ).

3. Put EOBs on a pedestal. Everyone in your back office can speculate about why they believe the insurer denied your urologist's claim, but only the explanation of benefits provides the carrier's ultimate reason. Make sure the coders who read your EOBs do more than enter charges. They should analyze your EOBs to accurately understand the reasons for denial and partial payment.

Sometimes the EOB will reveal an easy-to-correct problem. For instance, a typographical error on your part caused your software to accidentally cut off part of your urologist's UPIN on your claim form, so the insurer denied your charges. Other times, you'll have to investigate further to find the cause of the claim denial.

4. Call about unpaid claims at 30 days past due. You should run a report every month that lists all claims 30 or more days past due on which you've seen no activity in the last month.

Run the report based on balance size, from largest to smallest, and then have your billing staff follow up and match the account against the EOB to determine whether you need to appeal the claim, resubmit it, or contact the patient to cover the balance.

5. Run reports as backup. Reading your EOBs and calling to follow up on unpaid claims should reveal most of the reasons for your denials, but you can find out more if you run additional reports. See our article "Manage Your Urology Claim Denials in Half the Time" at right for details about which reports you should run to keep your practice operating smoothly.

6. Look for trends and patterns. Whether you're analyzing EOBs, calling about unpaid claims or reading monthly reports, you should look for unusual trends or patterns in denials. If a type of denial (from a specific payer, on a certain procedure, etc.) begins to form a pattern, you should contact the payer to determine why it systematically denies all claims for that service.

Good idea: Tracking denials by provider is important as well because you can see the root cause of some errors, such as erroneous coding. So you can try forming more than one top-10 list each month--perhaps an overall  top-10 list and then separate lists for different providers and different stages of the denial management process (payment posting, A/R follow-up, etc.).

Free spreadsheet: For a spreadsheet to help you track denials by provider, e-mail editor Torrey Kim at torreyk@eliresearch.com.

Bottom line: Once you effectively gather the monthly data to shape your top-10 denials list, you'll need to share the list with staff and providers and use the information to address and correct the causes for denial.

For example: A common denial reason in urology practices is that the urologist has linked the wrong ICD-9 code to a procedure. For example, says Andrea Denowich, a practice management consultant in Dallas, the surgeon will convert a laparoscopic procedure to an open surgery but will forget to append V64.41 (Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis code.
 
Another common denial happens when physicians forget to append a modifier, such as 78 (Return to the operating room for a related procedure during the postoperative period) when the urologist performs a procedure during the patient's global period. The only way to combat the problem, Denowich says, is to continually hold sessions showing surgeons how much money they lose by coding improperly. "Education is key," she says.

Want more info? Flip to the article "Do These Top-10 Denials Look Familiar? Check Your List" included with this issue to compare your top-10 list to Medicare's list of top-10 reasons for rejected claims.