Coding Corner: The top five essential tips for successful appeals

August 01, 2013
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

How you present appeals to your carrier can make a difference between success and failure. Here are the top five tips to achieve success.

5. Be prepared

Anyone speaking with the carrier regarding an appeal – whether coder, biller, office manager or physician – should have the knowledge and specific information necessary to discuss that appeal, in full. The caller should be able to review the operative note with the payer, to explain the rationale for the coding/billing and to demonstrate why the claim should have been treated differently.

4. Write a proper appeal letter

Don’t just send an explanation of benefits (EOB) with a balance bill. The payer shouldn’t have to guess the problem. Instead, you should spell out for the payer exactly what you wish them to review (such as fees, coding denials, etc.). You’ll have to spend a few extra minutes to put your request in writing, but it can make a big difference.

3. Correct the claim before you appeal

If the original claim was incorrect, appealing with the same claim will not change your results. Double-check the claim’s EOB, CPT® coding, diagnoses and documentation to be sure it is correct. Be absolutely certain you are applying modifiers appropriately. Adding modifiers (e.g., modifier 59 Distinct procedural service) to a claim does not guarantee payment, and may lead to accusations of fraud or abuse.

When you’ve finished reviewing the claim, make the necessary changes and/or documentation addenda before resubmitting.

2. Code only what documentation supports

If you are billing a surgery, review the body of the operative note to be sure that all the procedures reported actually were performed. A common mistake is to code from the “list of procedures performed” at the beginning of the operative note. As payers and auditors know, these lists often do not accurately reflect what occurred in the operating room. A careful reading of the operative note might even reveal separately reportable procedures that would have been missed if relying only on the note summary.

Similarly, coders shouldn’t rely on a physician’s recommended coding, but should instead review the documentation to be sure they are reporting the correct codes. If necessary, the physician should be prepared to amend the record to better reflect the nature of the service and/or the patient’s condition.

1. Avoid obvious mistakes

Payers will tell you (and audits confirm) that a staggering number of denials are the result of obvious errors, such as missed timely filing deadlines; illegible claims; claims not properly filled out (e.g., incorrect patient identifier info); failure to obtain pre-authorization; and wrong, insufficient or non-existent documentation. These errors can be avoided easily by double-checking claims prior to submission. It’s worth the time: You’ll receive payment quicker, and the payer does not have to process a denial EOB for an avoidable error. It’s a win/win. 


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