Top 7 Claim Denials

The best way to keep your income stream flowing properly is to prevent claim denials.  Read below for the top 7 denial reason codes and prepare a strategy to keep them to a minimum in your practice.

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

 

1.      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.

2.      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. 

3.      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.

4.      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.

5.      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

6.      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 proper claims reimbursement on the first submission.

7.      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.

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.

Medicare Prepayment Review of E and M Services

TheCMS Medicare Administrative Contractor (MAC), Palmetto GBA recently published the results from prepayment reviews of Evaluation and Management codes 99204 and 99205.

Evaluation and Management services are the most commonly provided service and the most likely to be subject to miss-coding.  CMS and individual MAC’s have published numerous guides, fact sheets and even an interactive coding tool to assist providers in selecting the proper level of the E and M service.

 Follow these links for helpful information on E and M coding:

Documentation Guidelines for Evaluation and Management (E/M) Services

Evaluation and Management Services Guide

E/M Review Checklist and Score Sheet Tool

This brought to my attention, maybe there are other MAC’s currently scrutinizing the same or similar services in their jurisdictions.  And, maybe there are providers out there that are unaware that they are undergoing a “Prepayment Review” when they are passing on their charge code to office staff.  So, with that in mind, I researched the information found on each MAC website and compiled a location and procedure list.  Since the procedures selected are known to be both performed at a high volume and have a high error rate, by reviewing the criteria for these codes, a provider can ensure he/she is compliant when making a code selection.

MAC	Jurisdiction/State(s)	CPT Code(s)	Specific Provider Types Effected
Cahaba Government Benefit administrators	J10: Alabama, Georgia, Tennessee	99214-99215 99223, 99233	Unspecified
Cigna Government Services	J15: Ohio	99310	Unspecified
First Coast Service Options	J9: Florida	99201-99205 99211-99215 (when billed with a 24 modifier)	Unspecified
First Coast Service Options	J9: Florida	99215	General practice Optometry Osteopathic manipulative medicine Pediatric medicine Podiatry
National Government Services	J6: Illinois, Minnesota, Wisconsin	99205, 99215 99223, 99233	Unspecified
National Government Services	J13: Connecticut, New York	*99223 **99233 ***99215	* General Surgery ** Cardiology and Gastroenterology ***Hematology/Oncology
Palmetto GBA Click herefor results	J1: California
	Northern California	*99204 **99205	*Family Practice and Ophthalmology ** Internal Medicine and Neurology
	Southern California	*99204 **99205	*Otolaryngology **Internal Medicine and Neurology
Palmetto GBA Click here for results	J11: North Carolina, South Carolina, Virginia, West Virginia	99233	Unspecified
Wisconsin Physicians Service Ins. Corp.	J8: Indiana	99233	Unspecified

National Minority Donor Awareness Week Begins Today

Today, August 1, starts National Minority Donor Awareness Week, to increase awareness of the need for more organ, eye, and tissue donors, especially among minorities.  56% of those persons on the donor waiting list are minorities.

 One organ donor can save 8 lives and a tissue donor impacts up to 50 lives.  Someone is added to the waiting list every 10 minutes.  Each day an average of 79 people receive organ transplants while an average of 18 people die waiting for transplants.

The need for additional minority donors is affected by a disproportionate demand due to higher incidences of diseases resulting in the need for an organ transplant. The table below illustrates the disparity. 

African Americans comprise 13% of the population; however they represent 34% of those waiting for a kidney, and 22% waiting for a heart.  Similarly, Hispanics/Latinos comprise 16% of the population, but equate to 19% of those waiting for a kidney, and 17% waiting for a liver.  Asians are 5½ times more likely than Caucasians to develop hepatitis B and Native Hawaiians and other Pacific Islanders are 7 times more likely to develop chronic liver disease and 3 times more likely to develop diabetes. 

Even though race/ethnicity is not the deciding factor in matching organs there is a higher likelihood of someone waiting for an organ transplant receiving one if there are large numbers of donors from their racial/ethnic background. This is because the critical qualities of compatible blood types and tissue markers are more likely to be found among members of the same ethnicity.

Data based on information found on organdonor.gov

May 2013-Composition of the Organ Donor Waiting List	Percentage of deceased donors for 2012	Difference between need and availability of same race donors
44% Caucasian	66% Caucasian	22% more than needed
30% African American	17% African American	13% less than needed
18% Hispanic/Latino	13% Hispanic/Latino	5% less than needed
7% Asian/Native Hawaiian/other Pacific Islander	3% Asian/Native Hawaiian/other Pacific Islander	4% less than needed

According to the United Network for Organ Sharing (UNOS.org) waiting list of candidates as of 7/29/2013 at 12:27pm:

*All	118,943
Kidney	96,966
Pancreas	1,183
Kidney/Pancreas	2062
Heart	3,536
Lung	1,673
Heart/Lung	48
Liver	15,766
Intestine	254

*All candidates will be less than the sum due to candidates waiting for multiple organs

> More about African Americans and organ donation
> More about Asians, and Native Hawaiians and other Pacific Islanders and organ donation
> More about Hispanics/Latinos and organ donation
> Learn about National Minority Donor Awareness Week

How to Appeal a Medicare Denial

If you have received a claim denial from your Medicare contractor you do have the right to submit an appeal.  If you do not take assignment on the claim, your appeal rights can be limited.

  See section at the bottom on Clerical Reopening when an appeal is not indicated.

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration 

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ) 

If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

By clicking here you will find information on the OMHA website.

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.

By clicking here you will find information on the Medicare Operations Division/Medicare Appeals Council.

Fifth level of appeal: Judicial review
If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.

• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

Additional resources

Within the CMS websites you will find information related to the five levels in the Part A and Part B appeals process.

• CMS Appeals Web resources

• CMS Appeals process flowchart

CMS resource materials available for download

• MLN - The Medicare Appeals Process Brochure

CMS Internet-only manuals: Publication 100-04

• Chapter 29– Appeals of Claims Decisions

• Chapter 34– Reopening and Revision of Claim Determinations and Decisions

Minor errors or omissions on some Part B claims can be corrected for reprocessing using the clerical reopening process.

There are two ways to initiate this process:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone re-openings on certain claims.  For the IVR reopening request help sheet, click here

• For reopening requests in writing, use the clerical reopening .

Common clerical errors consist of:

• Mathematical or computational mistakes

• Transposed procedure or diagnostic codes

• Inaccurate data entry

• Misapplication of a fee schedule

• Computer errors

• Denial of claims as duplicates which party believes incorrectly identified as duplicate

• Incorrect data items such as provider number, modifier, date of service

“Incident to… “What Does That Mean?

Many terms used in the “rules” for medical billing seem like they belong more in a law book, than a billing guide.

 That is how I start to feel when reading about billing “Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service.”

 For my enlightenment and hopefully yours, I have attempted to glean the basics from about 10 pages in section 60 of the Medicare Claims Processing Manual, Chapter 15 “Covered  Medical and Other Health Services”.

 Let’s start with an easy concept: An incident to service or supply is a service or supply not covered in one of the other benefit categories.  The other benefit categories are:

·         Drugs and Biologicals
·         Sleep Disorder Clinics
·         Diagnostic X-Ray, Diagnostic Laboratory and Other Diagnostic Tests
·         X-Ray, Radium and Radioactive Isotope Therapy
·         Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
·         Durable Medical Equipment
·         Prosthetic Devices
·         Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
·         Therapeutic Shoes for Individuals with Diabetes
·         Dental Services
·         Clinical Psychologist Services
·         Clinical Social Worker (CSW) Services
·         Nurse Midwife (CNM) Services
·         Physician Assistant (PA) Services
·         Nurse Practitioner (NP) Services
·         Clinical Nurse Specialist (CNS) Services
·         Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech Language Pathology Services) Under Medical Insurance

 To see the details of services that fall into these benefit categories, you can access the Medicare Claims Processing Manual, Chapter 15 by clicking here.

Well, now that has narrowed things down quite a bit. Let’s look at the next part that makes a service or supply “incident to”.  It is considered:

·         Integral to the performance of the *physician’s professional service
·         Commonly rendered without a separate *physician fee and furnished in *physician’s offices or clinics

 Supplies commonly considered “incident to”: gauze, ointments, bandages, oxygen

·         Furnished by the physician or by **auxiliary personnel under the *physician’s *** direct supervision

 Services of auxiliary personnel are considered incidental to a physician service when they assist in rendering the service, and the charge is included in the physician’s bill.  This also applies if auxiliary personnel perform a subsequent service as part of a course of treatment initiated by the supervising physician.

*Physician: includes physician, physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, clinical psychologist.

**Auxillary Personnel:  personnel whether employee, leased employee, or independent contractor that acts under the supervision of a physician.  May include services by Non-physican practitioners: certified nurse midwives, clinical phychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialitsts.

***Direct supervision: the physican must be present in the office suite and immediately available to assist the auxiliary personnel in preforming the service.

Special Rules for Homebound Patients and Incident to Services

In medically underserved areas the shortage of medical personnel to provide certain medical services to homebound patients allows for an exception to the direct supervision rule.  In these circumstances, nurses, technicians and other physician extenders may provide these services under the *general supervision requirement instead of the direct physician supervision requirement.

*General supervision means that the physician is not physically present at the place of residence when the service is performed, but is under his/her overall supervision and control.

Services that can be covered incident to under general supervision: Injections, venipuncture, EKGs, therapeutic exercises, insertion and irrigation of sterile catheter, changing of catheters and collection of catheterized specimen for urinalysis and culture, dressing changes, replacement and/or insertion of nasogastric tubes, removal of fecal impaction, sputum collection for stain and cultures, paraffin bath therapy for hands and/or feet, teaching and training the patient for care of colostomy, ileostomy, or tracheostomy, testing urine, care of diabetic feet and blood pressure monitoring.

The specific criteria for “Service Incident to a Physician’s Service to Homebound Patients under General Physicians Supervision”:

·         The patient is *homebound

*Homebound: a patient is considered homebound if they possess a normal inability to leave home, such that leaving the home would require a considerable and taxing effort.

·         The service is an integral part of the physician’s service to the patient and done under general physician supervision.

·         The physician orders the service, maintains contact with the employee and upholds all responsibility for the service.

·         The physician or clinic has an associated expense and their bill includes the fee for the rendered procedure.

·         Any service performed is medically necessary and reasonable and unavailable by a Home Health Agency.

Medicare Incentives for EHR and PQRS

Ideally, the only responsibility of a physician is to provide the best care to his/her patients.    Unfortunately, medicine is a business, so the topic of reimbursement will always rear

its ugly head.

Providers of Part B services on the MPFS can increase reimbursement and avoid future penalties by taking advantage of Medicare incentives for EHR and PQRS reporting.  Below you will find guidance on

both of these programs to help improve your bottom line.

To qualify for Medicare PQRS incentive payments, EPs must sufficiently report on the applicable quality information measures.  In the PQRS 2013 program, there are several hundred measures.

 To help navigate through this complex process, you can access the “Getting Started” page of the CMS PQRS website by clicking here.

Advanced Practice management software like Iridium Suite, has an integrated PQRS claim scrubber.  The practice can configure the medical billing system to automatically request that the physician sets up PQRS measures for each patient. The claim scrubber also recognizes which billing codes are potential PQRS denominators and automatically suggests the PQRS numerator codes that should be added to the claim. The biller simply accepts these suggestions and the claim scrubber automatically adds the proper PQRS charge codes to the claim.

  To qualify for the Medicare EHR incentive payments eligible professionals (EPs) must utilize certified meaningful use EHR technology. Proof of meaningful use can only be demonstrated by reporting clinical quality measures (CQMs) as well as the meaningful use measures.

Providers wishing to purchase certified EHR software can access a list of options on the CMS site by clicking here.

 In 2013, EPs may satisfy the meaningful use objective to report CQMs to CMS by reporting them through:

• Medicare and Medicaid EHR Incentive Programs’ web-based Registration and Attestation System

EPs who choose to report CQMs through the CMS Attestation system must still report information on individual quality measures or measure groups using one of the four reporting options in order to also participate in PQRS.

• Participation in the PQRS-Medicare EHR Incentive Pilot, which utilizes the 2013 PQRS EHR Measure Specifications.

 EPs who participate in the pilot may submit their meaningful use objectives through the CMS Attestation system, and then complete a single submission of CQMs to receive credit for both programs.

EPs who successfully participate in PQRS and EHR can receive an incentive in 2013 and avoid the 2015 payment adjustment for both programs.

Participating in both the PQRS and EHR programs in 2014 and beyond is being simplified by CMS with the alignment of several of key components.

Here are the changes affecting PQRS and EHR in 2014:

• PQRS and EHR programs will align on the same set of eCQMs (64 total) and the same electronic specifications
• All Medicare-EPs beyond their first year of demonstrating meaningful use will be required toelectronically report their CQM data to CMS for the EHR program
• Submitting data electronically using 2014 certified EHR technology will meet the standards forboth EHR and PQRS programs
• Participating EPs will have the option to submit patient-level data (via QRDA I) or aggregate data (via QRDA III) using the same reporting mechanism for electronic reporting for both programs.

Click here to read about how your EHR can communicate with your medical billing software.

Get Your Comments Ready: Proposed Changes to the 2014 Medicare Physician Fee Schedule

The Proposed Rule that details changes affecting the Medicare PFS will be published July 19, 2013 in the Federal Register.  This begins the comment period that continues until Sept. 6, 2013.

If you want to participate in the comment process, you need to start somewhere.  The best place is here, with a brief description of the key elements in the proposal.

Telehealth Services: These services would be expanded to include areas designated as health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy.  Additionally, transitional care management services would be considered eligible telehealth services.

Revisions To The Practice Expense Geographic Adjustment:  PFS rates are calculated based on numerous factors as required by the Medicare law. The main goal is to adjust payments according to geographic differences in practice costs.  To accomplish this, CMS assigns separate geographic practice cost indices (GPCIs) to the work, practice expenses (PE), and malpractice cost components of each of more than 7,000 physicians’ services.   The proposed changes to the GPCIs would be phased in over 2014-2015 and are:

• New GPCIs using updated data as required by law every 3 years.

• Changes to the weights assigned to each GPCI (work, PE and malpractice) consistent with the recommendations of the Medicare Economic Index (MEI) Technical Advisor Panel (see below) that increases the weight of work and reduces the weight of practice expense.

• The proposed GPCIs reflect the elimination of the work “floor” and as a result 51 localities will have a work GPCI below 1. 

Medicare Economic Index: MEI, the price index used to update the PFS for inflation, and sustainable growth rate are used in when calculating the total payment amounts in the PFS.  The proposal reflects 2012 recommendations by a Technical Advisory Panel CMS that will revise the calculation of the MEI as well as changes in the RVU and GPCI weights assigned to work and practice expense to align with the MEI.

   Miss-valued Codes: CMS as part of the ACA, has identified miss-valued codes requiring adjustment to payment rates.  There are more than 200 codes with proposed rate changes.  These codes currently reimburse higher for services performed in an office versus the fee paid in a hospital outpatient setting or ASC.  The proposed rates would reflect a PFS office place of service reimbursement that is equal to the sum of the reimbursement to the facility and practitioner when service are rendered in an outpatient hospital or ACS place of service.  There have been additional miss-valued codes identified by Medicare Contractors based on claim review that have proposed reimbursement changes.

Application of Therapy Caps to Critical Access Hospitals: They are proposing outpatient therapy services furnished in CAHs are added to the therapy cap limitations.  This would apply two per beneficiary of the following outpatient therapy services:

• physical therapy and speech-language pathology services
• occupational therapy services.

Future change for 2015 included in this proposal:

Primary Care and Complex Chronic Care Management: The proposal would provide for an additional, separate payment for a practitioner that provides non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more).  This is how it would work:

• Coverage is based on the physician development and revision of a plan of care, communication with other treating health professionals, and medication management
• Beneficiaries  would  be required to have an Annual Wellness Visit (or an Initial Preventive Physical Examination (IPPE), if applicable)
• Would apply to a single practitioner that agrees to furnish these services and that obtains the beneficiary’s consent to receiving these services over a one-year period.  
• Medicare would make the separate payment through two G-codes for establishing of a plan of care and furnishing care management over 90-day periods.

Included in the proposal are guidelines to develop practice standards that would support this payment.  This may include requirements like real time access to records via HER and written protocols detailing the care management process.

To access the CMS Fact Sheet click here.

To read the entire proposed rule click here.