How To Reduce Claim Denials

Author(s): 
By Anthony Poggio, DPM

   Getting a denial for claims is, at best, upsetting for both the doctor and staff. Often, the doctor sees this in a negative light. If the dollar amount in question is small, he or she may totally disregard it, believing it is “not worth it” to appeal. When repeated problems involving specific CPT or ICD-9 codes occur, DPMs sometimes select alternative coding choices, which may not be the best option either.    Instead of looking at a claim denial as a defeat, try to look at it as an educational opportunity. Unless one understands the reason for the denied claim, the doctor or staff will more than likely repeat that error over and over again. Some doctors have stopped billing for certain services altogether and they are essentially providing services for free. Even if the dollar amount in question is small, that small amount can add up to a considerable sum of money over time. Taking the time to correct these errors will lead to proper payment, more revenue, less billing stress and decrease one’s audit exposure.    It is important to inspect the explanation of medical benefits (EOMBs) carefully as these documents contain valuable information as to why the claim was denied. Check all of the various insurance denial codes/messages. Medicare, in particular, has limited numbers of denial messages to select from when assigning a denial reason so the selected denial reason may be vague. There are often other clues/denial messages on the EOMB as to why the claim was denied. If you are unable to figure out why the claim was denied, call the carrier directly or seek counsel from a reputable source. I would suggest checking with the local or state society regarding whom to call to get billing advice as well as accurate answers to questions.    Granted, some denials are the result of poor carrier policies, which do not seem to reflect common office practices, or they occur due to harsh interpretation of billing codes/modifiers, etc. However, many claim denials are the result of sloppy billing practices. With this in mind, let us take a closer look at common billing miscues.

Essential Insights For Rectifying Incorrect CPT-ICD-9 Codes

   One common error is listing incorrect CPT-ICD-9 combinations on the claim form. Patients may have more than one condition so several ICD-9 codes may be required. However, each individual CPT code must correctly align with a proper ICD-9 code. For example, if a patient presents with fasciitis and a verruca, an injection code should match up with fasciitis and the skin destruction code should match up with the verrucae. If the CPT/ICD-9 codes get switched (i.e., listing a skin destruction CPT code with a fasciitis diagnosis code), this will not make any sense and the claim will be denied.    List only the ICD-9 codes that are necessary in Box 21. Listing multiple ICD-9 codes may confuse claims processing. For example, if the patient is diabetic and has a neuroma that is injected (CPT 20550), list only the neuroma diagnosis since the neuroma is the basis for payment of the injection, not the diabetes. Similarly, if one is treating a painful ingrown nail via debridement, use the appropriate pain and nail diagnosis that the carrier allows. If one lists diabetes and peripheral vascular disease (PVD) on the claim as well, the computer may look for a Q code, which is required for diabetes with PVD but not for a painful condition.    Also make sure that the ICD-9 and CPT codes are valid at the time of service. Medicare no longer will offer a grace period for changes in ICD-9 codes. It is essential to stay on top of new coding changes.    Keep in mind that there may be more than one way to list a certain diagnosis. Check with the carrier (especially Medicare’s Local Carrier Determinations or LCDs) about which codes it allows. If one does not select one of the allowed ICD-9 codes, the claim will be denied. One may have performed a procedure that is medically necessary and reasonable but if the wrong ICD-9 code is used, the claim will be denied.

How To Avoid Mistakes When Billing For Physical Therapy

   Make sure the listed physical therapy modalities are legitimate for the treated diagnosis. There needs to be an “order” in the chart (similar to what one would give a physical therapy facility). This physical therapy order should list the diagnosis, treatment modalities, frequency of treatments, goals and expected duration.    Excessive visits can also trigger a denial. Some plans only allow for a fixed number of physical therapy visits over a certain time period. Some may limit the number of treatments per diagnosis while other insurers may limit the number of treatments on a yearly basis for all diagnoses and providers. Always check with the carrier for benefits, deductibles and policy limitations before proceeding with providing physical therapy treatments. Also find out if there are any requirements as far as notification to the patient once any allowable limits have been exceeded and what one may charge for those non-covered visits. You may be able to bill your usual and customary fees for those non-covered services.    Do not submit claims for physical therapy modalities, such as hot/cold packs, that patients can apply or use themselves. Some insurance carriers will question massage and whirlpool services. Although these modalities may make the patient feel good, they may not offer significant therapeutic value in the long run to warrant reimbursement. Be sure to list in the chart any home treatments/modalities/exercises that you instructed the patient to do on his or her own.    Also keep in mind that billing multiple modalities on the same date of service may also cause carriers to question the claim. Are one or two modalities as effective as three or four?

Secrets To Obtaining Accurate Reimbursement For X-Rays

   When documenting the use of X-rays, note the body part that was X-rayed, which views you obtained and the number of views you obtained. Take the necessary number of views. Are three views medially necessary and reasonable, or would two views suffice?    Similarly, are bilateral X-rays required? Will evaluating the osseous structure of the opposite foot affect the treatment plan? If so, list this in the chart. If the patient has a symptomatic bunion on the right foot and you are only planning to address the right foot, is it necessary to obtain an X-ray of the left foot? That point could be argued. However, contrast this with taking a limited X-ray of the contralateral foot to see if the changes one sees on X-ray are consistent with fracture/avulsion versus a natural ossicle or bipartite sesamoid.    When it comes to billing for multiple X-rays, use the modifiers RT and LT for clarification. Otherwise, they may be deemed as duplicates. Be sure to use appropriate diagnosis codes for an X-ray service in order to attest to the medical necessity of that service.    If pre- and post-procedure X-rays are required, which is the case for example when performing a closed reduction of a fracture, bill the second set of X-rays with a 76 modifier.

Pertinent Pearls For Correctly Documenting DME

   A common denial problem with durable medical equipment (DME) is listing the inappropriate place of service. Generally, home is the proper place of service (POS), not the office. Many of our computer systems default to POS 11. If one does not catch this error and change it on the claim form, the claim will be denied.    Use the proper HCPCS code (and modifier if required) for the supply item. Although a device is medically necessary and reasonable, the billing code one selects may not be correct. One common error is using an AFO code for either cam walkers or night splints. Again, it is important to keep up with changing codes and regulations. For example, Medicare will not allow payment for a cam walker for the treatment (offloading) of an ulcer.    For pneumatic cam walkers, use L4360. For non-pneumatic cam walkers, use L4386. For a night splint, use L4396.    As a final word on DME code selection, do not rely solely on the recommendation of manufacturers as to which is the correct HCPCS code to use for their product. Verify any code with the DME carrier.    Make sure your Medicare DMERC license is valid. Without a valid DMERC license, one cannot dispense covered DME items to patients. Similarly, when dealing with other private insurers/HMOs, make sure they recognize you as a designated supplier. Otherwise, there may be no recourse to collect the money for the item from either the carrier or even possibly the patient.    Many HMOs have designated suppliers. Patients can obtain DME items from these designated suppliers under the plan’s coverage allowances or pay cash for these items in your office. If a patient wishes to obtain a DME item from you as opposed to a designated supplier, be sure to clearly explain the financial differences or this can lead to a very unhappy patient.

What Does Billing For Surgery Require?

   Prior to performing any surgery, check to see if prior authorization is required. Record the name of the person you spoke with, the date and time of the conversation and what both parties said. Also make sure the facility (this would include the office surgical suite) is allowed. If the insurer does allow an in-office surgery, ask about authorization for a surgical tray.    Billing for foot surgery often requires billing multiple codes since surgeons can often perform digital, forefoot, midfoot and rearfoot procedures in one setting. Check with each carrier about which bundling software it employs so you can bill properly for the services you performed. The proper use of modifiers is very important. Start with the T modifiers to identify a surgery performed on specific toes. T modifiers only apply to the phalanges distal to the metatarsophalangeal joint. Do not use T codes to identify metatarsal work. For metatarsal and more proximal work, one should also use RT and LT modifiers whenever possible. If those two are not appropriate, use the -59 modifier.    Also check the code series for the surgery performed as there may be a single code allowed for similar procedures or it may be lumped into a single, multiple code. For example, CPT 28740 is for fusion of a single midtarsal or tarsometatarsal joint. There is also CPT 28730 for fusion of multiple (or transverse) midtarsal or tarsometatarsal joints. Accordingly, billing CPT 28740 and CPT 28740-51 for the fusion of two of these joints would be incorrect. CPT 28730 would be the correct, more inclusive choice. Conversely, when it comes to performing arthroplasties on two toes, one may bill this twice by using CPT 28285 (with the appropriate T modifiers) as there is no more inclusive code.    Another example would be billing for multiple nail avulsions. The proper coding would be CPT 11730 for the first nail avulsed and 11732 for each additional nail thereafter. Multiple 11732 billings would then require the use of T modifiers.    The use of internal fixation is included in the surgical fee. The use of external fixation may be payable separately if it is deemed medically necessary and reasonable.    When it comes to removing hardware (such as an exposed K-wire) that is intended to be removed, this is not reimbursable separately. Deeper/buried forms of fixation may be payable if medically necessary and reasonable. The routine removal of internal fixation after surgery without symptoms or additional rationale would not be reimbursable.    Also be aware that anesthesia administered by the surgeon is never reimbursed separately. Similarly, do not bill for local anesthetic supplies. Only steroid medication is generally reimbursable.

Resolving Billing Issues In Routine Foot Care

   Coding for routine foot care still raises blood pressure throughout podiatry. Unfortunately, given the multiple Medicare carriers and the policy variations with each carrier, it can get very confusing.    CPT 11720, 11721, G0127 and 11719 are allowed for covered routine foot care for “at-risk” patients. Generally, Q modifiers are required only for vascular-based ICD-9 codes. The allowable systemic, vascular and neurologic ICD-9 codes may vary by carrier.    CPT 11720 and 11721 are also allowed for coverage for painful dystrophic nails in patients who are not at risk. Before billing care of symptomatic nails, check with the Medicare carrier for specific rules. When you are billing for the debridement of painful dystrophic nails, Medicare will only pay for those nails that one documents as being painful by history and examination. One should always include as much objective data as possible to document the fact that nails are painful and limit ambulation. Simply listing “the patient states they hurt” may not be enough.    When billing for calluses, use 11055, 11056 and 11057 for callus care in the at-risk patient. Again, Q modifiers are required when billing a vascular secondary diagnosis.    Some carriers may allow CPT 11040 for the treatment of symptomatic lesions. Again, check with the carrier about specific policies and billing protocols prior to billing symptomatic lesions.    Billing a combination of nails and calluses generally requires the use of the -59 modifier, not the -51 modifier, to separate the two billings correctly.    Carefully align nail care procedures with nail ICD-9 codes and align callus care procedures with callus ICD-9 codes. Sloppy billing often results in denials when billing for treatment of these conditions. Also be careful to clearly list and align at-risk conditions and painful conditions with the appropriate ICD-9 codes on the claim form.

Sorting Through The Intricacies Of E/M Coding

   One area of confusion with evaluation and management (E/M) is the use of the 25 modifier. Only use the -25 modifier on the E/M service when performing an E/M service and a procedure on the same day. For an E/M service to be payable, it must be “significant and separately identifiable” from the procedure. Every procedure has a component/allowance for evaluation and management included in the reimbursement fee. Once the diagnosis has been established and there is no significant change in treatment protocol, then an E/M service may not be payable separately from the procedure one has performed.    Generally, it is not necessary to add a -25 modifier to the E/M service when billing a new patient visit code and a procedure performed on the same day. The initial code series itself implies this is a new problem. For Medicare, the only exception to this is when billing nail care codes CPT 11720, 11721, G0127 and 11719. Due to the CCI edit, one should add the -25 modifier to the initial visit E/M code to allow proper payment for both services. That said, each private carrier and some Medicare carriers may have other requirements.    The bottom line is to use this modifier only when indicated. Using this code on virtually any E/M service may make one’s claims look suspicious.

Key Tips For Ensuring Proper Casting Reimbursement

   Medicare will pay for cast application when it is medically necessary and reasonable. When one applies a cast at the time of surgery, it is included in the surgical allowance and is not payable separately. Subsequent casts would be payable separately. Bill post-op casts with a -58 modifier.    Cast supplies are only payable with a diagnosis of a fracture or a dislocation. Consequently, cast supplies associated with application of a cast for tendonitis, fasciitis and even a total contact cast are not reimbursable even though the cast itself may be reimbursable.    Do not use CPT 29515 (application of a short leg splint) when casting for orthotics. The best code to use when casting for orthotics (for those carriers which allow this) is the unlisted casting code CPT 29799. This code would include either unilateral or bilateral orthotic mold fabrication and the actual plaster (or other) supplies.

In Summary

   Hopefully this article has clarified some common billing scenarios that often result in claim denials. It is important to monitor one’s billing practices as part of the office compliance program. Being aware of new changes in policies and learning from errors can go a long way toward avoiding repeat claim denials. Dr. Poggio is a California Podiatric Medicine Association Liaison to the National Heritage Insurance Company and a medical consultant to Health-Net Insurance Company. Dr. Poggio is a member of the American College of Podiatric Medical Reviewers and is board-certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.

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