星空入口

Hint: See impact of modifiers.

Even the most seasoned coders make mistakes, but denials are not something you want to experience in your practice.

Unfortunately, denials have been steadily increasing since 2016, according to Holly Ridge, BSN, RN, CPC, CPMA, manager of medical necessity and authorization denials for Duke Health in Durham, North Carolina.

As a coder, you must pay attention to even the tiniest of details to minimize the risk of denials. 鈥淭here are people in the office that don鈥檛 understand that if there are seven characters required, that there may be placeholders needed for the fifth and sixth character to get that to a D or S,鈥� said Jennifer Swindle, RHIT, CCS, CCS-P, CDIP, CPC, CIC, CPMA, CFPC, CEMC, 星空入口Fellow, in a presentation titled 鈥淭op Denials and How to Work Them Effectively and Prevent Them in the Future鈥� at AAPC鈥檚 2023 virtual REVCON.

Learn how to keep denials at bay in your practice.

Beware of Ripple Effects

Sometimes, denials happen because too many dominoes fall. Having a set-in-stone, comprehensive policy of verifying patient insurance can forestall a host of denials.

One of the most common times you鈥檒l see a timely filing denial is when you file to the wrong payer, Swindle says.

For example, a claim may get denied because it wasn鈥檛 filed in a timely fashion 鈥� but then you find out that, actually, the claim was filed with a payer that no longer covers the patient. So, by the time the billing staff figures out what went wrong, the claim submission to the correct, current payer is no longer timely.

Remember: Payers set their own rules about when claims must be filed, so your billing staff needs to keep the rules straight for each respective payer 鈥� and claim.

In this situation, some payers may provide a little grace, if you can produce some proof.

Furthermore, if you can produce documentation proving that the claim was sent and received by a payer within the allowed timeframe, that gives you 鈥渁 little bit more leg to stand on, to show, 鈥榟ey, we did our job and we got this out the door,鈥欌�� Swindle said.

It鈥檚 crucial to make sure you鈥檙e monitoring the claims you submit, because some timely filing denials may be your responsibility, even if you got them out the door on time and to the correct payer.

鈥淪ometimes payers say, 鈥榃e didn鈥檛 get a claim.鈥� You sent it, you鈥檝e got records in your system, you show where the claim was generated 鈥� but they never received it. If they didn鈥檛 receive it, and you get a timely filing denial, that鈥檚 still on you, because they didn鈥檛 have it. So, you want to really monitor those,鈥� Swindle warned.

Beware The Foibles of Hard Copies

While a lot of payers accept claims electronically, some providers and payers use hard copies. Mailing records involves several situations where things can go wrong and result in a denial.

Swindle suggests says people submitting paper claims and receiving denials on those claims should check these data points:

• Are you sending things to the right address?
• Is it going to the right department at that address?
• Does the right person receive it, who can and will advance the claim to the next step in the process?

If you have a payer that routinely says they鈥檙e not receiving claim submissions, consider sending some claims via certified mail. 鈥淚 certainly don鈥檛 recommend that you send everything certified. It can get very cost prohibitive if you鈥檙e doing it on everything you鈥檙e sending,鈥� Swindle said.

If you don鈥檛 have that certified mail signature as evidence, it鈥檚 almost impossible to prove that you mailed a claim, she explained.

Understand How Situations are Affected by Modifiers

Modifiers can impact many facets of documentation, but their impact on the revenue cycle may be outsized. 鈥淢odifiers can be a problem if they鈥檙e overused, misused, or not used. All have a different risk,鈥� Swindle said.

Reporting a service without a correct modifier may lead to denials with explanations like the service being inclusive with another service, services integral to another service, services bundled, services not payable with another service.

A working knowledge of appropriate modifier usage, including being aware of any National Correct Coding Institute (NCCI) edits, is crucial for getting claims paid. And remember, even in situations where a modifier is allowed, it may still not be appropriate, but any modifier usage can and should be supported by documentation.

Swindle noted that modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) usage is particularly scrutinized, and providers may be notified that they鈥檙e using modifier 25 more than their peers.

You need to make sure you鈥檙e doing it right, but just because your provider gets 鈥渁 letter that says 鈥榶ou鈥檙e using modifier 25 more than your peers鈥� absolutely does not mean that they should quit using it. If they鈥檙e using it appropriately, and their services are supported, and their documentation supports it, it doesn鈥檛 matter if they use it more than their peers,鈥� Swindle said.

鈥淲e want to make sure that we鈥檙e not using modifiers to get paid when it鈥檚 not appropriate that we get paid. But we want to make sure we鈥檙e using modifiers when we need to, to get appropriate reimbursement,鈥� she said.