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.

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