The best way to keep your income stream flowing properly is to prevent claim denials.

You should be aware of the following high volume denial reason codes and prepare a strategy to keep them to a minimum in your practice.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, many of these types of denials will become a thing of the past.

18 - Duplicate claim/service.

Manual keying of services lends itself to duplicate entry of those services.   A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.

    16 - Claim/service lacks information which is needed for
                                  adjudication.

Some payers have specific claim rules that require “non-standard” 5010 format information be included on their claims.  An example is the rendering provider’s Taxonomy code in addition to the standard NPI.  Iridium Suite allows the user to include this specialized data on the claims to those individual payers as needed. 

97 - Payment is included in the allowance for another
                              service/procedure.

Government payers, such as Medicare, as well as the larger Commercial payers have adopted the NCCI standard for “bundled” services.  The Iridium Suite Claim Scrubber comes standard with all current NCCI edits built in.  The Scrubber alerts the user when entering two or more procedures that are considered inclusive of each other.

   29 - The time limit for filing has expired.

Payers each have their own time filing limits guidelines for claim submission.  It can be as short as 60 days, or the current Medicare limit is 12 months.  The sooner you submit your claims, the quicker you will receive your payment and eliminate the risk of untimely filing denials.  With the Connectivity Clearinghouse within Iridium Suite, you can import patient demographic and service data directly into the billing software from your EHR/EMR.  Your patient and charge entry process can be almost completely automated allowing for close to “real time” claims submission for your services.

  50 - These are non-covered services because this is not
                                deemed a ‘medical necessity by the payer.  

                      The key to preventing these types of denials is being aware

                      of your payers Medical Policies. These two Biller’s Blogs 

                      provide insight on both Commercial Payers and Medicare:

Reviewing Commercial Carrier Medical Policies

Understanding Medicare Fiscal Intermediaries LCD's

  140 - Patient/Insured health identification number and
                                  name do not match.

    By utilizing the Real Time Eligibility function in  

    Iridium Suite, you can virtually eliminate denials 

    like the one above or similarly “subscriber not  eligible

    at time of service.”  You will be able to successfully 

    submit charges to the correct active payer with the 

    proper identification number and receive your 

    appropriate claims reimbursement on the first 

    submission.

197 - Payment adjusted for absence of
                                precertification/authorization.

A medical billing software with the ability to indicate payers requiring authorization as well as track a multiple service/visit authorization as it is assigned to the performed procedures is crucial in assisting office staff with this issue.  Iridium Suite provides a specific area in the patient insurance information section to indicate authorization requirements and to record the authorization details.  Before a claim can be submitted, it is scrubbed for authorization requirements and will warn the user if the authorization is missing.  You are unable to submit the claim without the appropriate authorization.

   B15 - Payment adjusted because this procedure/service is
                                   not paid separately.

This denial occurs when submitting a procedure code that is part of a “set” without the accompanying procedure.  A medical billing software, such as Iridium Suite, gives the user the ability to set up special code rules.  The system will warn the user if a particular code is being submitted without the “partner” code, allowing you to correct the claim before submission to the payer.

By being aware of the common denials your practice receives, you can develop the necessary processes to prevent them before they happen. 

Having the best medical practice billing software, Iridium Suite, can give you a head start with its many advanced functions.