By Terri Scales
In evaluating occupational medicine clinic coding and billing practices, we have noted the following five commonly occurring errors that can be resolved with appropriate action.
Mistake One:
Documentation does not meet the level billed.
If you receive a denial stating “Documentation is incomplete or insufficient,” the documentation does not support the level of service billed. This type of denial can result in down-coding or outright denial by carriers.
Ultimately the documentation was lacking the required components for the Evaluation and Management (E/M) level billed. Additionally, documentation does not guarantee reimbursement, although documentation does play a critical role in reimbursement.
To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. Next, one must understand the three key components of the 1995 and 1997 E/M guidelines: history, examination, and medical decision-making. With a new patient visit, all three of the key components must be met. Two of the three must be met for an established patient.
Mistake Two:
Medical necessity was not established by the diagnosis.
Linking the correct diagnosis to the service billed might be a deciding factor for claims payment. When billing an insurance carrier, be sure diagnosis codes accurately correspond with the service provided. CPT and ICD-9 code linkage is identified in box 24E on the HCFA 1500 form. Diagnosis linkage communicates to the carrier why it was medically necessary to perform the services provided.
Box 21 of the HCFA 1500 contains four sub-sections where ICD-9 codes are used to describe the encounter. The primary diagnosis or reason for the visit should be reported first, followed by codes for other diagnoses listed in descending order of importance. In outpatient settings, it is not appropriate to code for “suspected” or “probable” diagnoses.
Mistake Three:
The biller decides not to appeal or does not know how to appeal a denial from the carrier.
There are many reasons why medical practices do not appeal denied claims. The most common are the belief that appealing claims will create an increased administrative burden on the practice, or the biller does not understand the denial or coding guidelines. However, not appealing denied or partially paid claims can be costly to the practice and will result in decreased revenue.
The first step to appealing a denial is identifying the reason for the denial. Was it a missing modifier, a diagnosis error, or even a keystroke error within the patient’s demographic information? Familiarity with coding rules is necessary when developing an appeal strategy. The appeal process should be supported with strong provider knowledge of applicable state workers’ compensation laws, CPT coding guidelines, ICD-9 coding guidelines, and even E/M guidelines.
The next step is verification of the provider’s documentation. Remember the adage: “If it wasn’t documented, it wasn’t done.”
The third step is to identify the appropriate address, fax number, phone number, and email address to submit the appeal. If writing an appeal letter, indicate the date, date of service, claim number, the amount charged, and medical provider name. Describe the denial and explain why you are writing and what you are requesting. Include any supporting documentation, such as letters of medical necessity from your physician, medical records, progress notes, radiology or pathology reports, etc.
If you decide to call the carrier about your appeal, it is important to document the name and title of the individual with whom you are in contact. It is also important to document the date/time of your call and make notes of your conversations. A friendly tone will help smooth the way.
Besides obtaining appropriate reimbursement, there is another prospective positive result from increasing the number of appeals a provider submits: disputing reduced or denied claims may prompt a carrier to correct its claims editing software and processes, which in turn helps streamline the entire process.
Mistake Four:
The diagnosis was not coded to the highest possible degree of specificity.
Providers must select ICD-9-CM diagnosis codes that provide the highest degree of accuracy and completeness, or the greatest possible specificity. For example, it is not appropriate to bill for a patient with rotator cuff syndrome using code 726.1. You must use one of the more specific codes that are available: 726.10 Disorders of bursae and tendons in the shoulder region, unspecified; 726.11 calcifying tendinitis of the shoulder; 726.12 bicipital tenosynovitides; or 729.19 other specified disorder.
Providers should also be aware that codes marked NOS (not otherwise specified) or “unspecified” indicate that there is insufficient information in the medical record to assign a more specific code. NEC (not elsewhere classifiable) indicates the code book does not have a code describing the condition.
Diagnosis codes range from three to five digits. Most three-digit codes require a fourth or fifth digit, and some four-digit codes require a fifth digit. Diagnosis coding is a three-step process.
First, review the medical record to extract the reason for the visit. Second, look up the illness, signs, symptoms, or condition in Volume 2, Alphabetic Index, and locate the corresponding code. Third, look up the corresponding code in Volume 1, Tabular List, and choose the most specific code that accurately describes the patient’s condition.
Every clinic should have access to a current ICD-9 code book. These books are updated annually, effective October
- After each ICD-9 annual revision, be sure to update the diagnosis code information in your electronic billing/practice management system and on any paper documents.
Mistake Five:
Your organization lacks a consistent way to review coding.
Appropriate steps should be taken to incorporate checks and balances into your organization’s daily routine when reviewing charges for possible errors and omissions. Coding errors result in payment delays and underpayments and may trigger a carrier audit. Educate providers and staff (front and back office) on the time-consuming aspects of claims appeals when errors occur and the value of complete documentation and correct coding.
A “claim scrubber “engine” supports coding processes and compliance, and it is an effective way to systematically review claims prior to submission to the carrier. Terri Scales, CPC, CCS-P, is the regional director of client services, Bill Dunbar and Associates, LLC, and BDA Claim Correct, a member of the NAOHP Vendor Program.
