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2 About the Speaker Nancy M Enos, FACMPE, CPMA CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group. Mrs. Enos has 40 years of experience in the practice management field. Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer. In July 2008 Nancy established an independent consulting practice, Nancy Enos Medical Coding ( As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses, outsourced coding services, chart auditing, coding training and consultative services and seminars in CPT and ICD-9 Coding, Evaluation and Management coding and documentation, and Compliance Planning. Nancy frequently speaks on coding, compliance and reimbursement issues to audiences including National, State and Sectional MGMA conferences, and at hospitals in the provider community specializing in primary care and surgical specialties. Nancy is a Fellow of the American College of Medical Practice Executives. She serves as a College Forum Representative for the American College of Medical Practice Executives. Approved

3 Agenda Trends that Cause Claim Denials? Can Medical Claim Denials be Avoided What Steps can I take to Correct a Claim Why don t all Payers Follow the CPT Rules? Approved

4 Trends that increase the opportunity for Payment Denials Health Care services across the country have been trending downward over the past several years due to several factors including: Economic downturn lingering in several markets which has: Reduced elective services Employers increasing deductibles and patient responsibility on benefit designs which potentially: Increases the risk for bad debt Patients may delay services making care more intense when finally addressed Provider Tiering Affordable Care Act (ACA) and the impact of health exchanges Payer mix will shift as more people have coverage, and change coverage upon re-enrollment Payer shift increasing towards government payers Baby Boomers enrolling in Medicare Advantage products vs traditional Medicare Payer policy changes: Arduous prior authorization processes including volumes of paperwork and clinical documentation up front (example: Smart Sheets) Increased usage of benefit management companies to steer or reduce utilization Health care reform transitioning from a fee for service model to global or performance reimbursement Approved

5 Revenue Cycle Components Patient Scheduling Registration Insurance Verification Financial Counseling Self-pay, co-pay collection Credentialing Revenue Cycle Referral Management Charge Capture Coding Charge Reconciliation Payer Relations Policy Review & Input Group Appeals Coding Edits Claim Submission Payment Posting Accounts Receivable & Collections Denial & Rejection Management Customer Service Data Mapping Charge Entry Charge Transfer Encounter Posting

6 Scheduling/Pre-Registration Failure to obtain a referral and/or authorization for the visit or appropriate procedure. You can attempt to file an appeal but most insurance carriers will not reverse their decision Denials due to any of the inaccuracies above can be refiled but instead of a 14 day payment turn around, it could take up to 30 to 45 days to finally get paid. Nancy Enos Medical Coding AAPC Approved

7 Scheduling/Pre-Registration Non-covered Services This is another reason why it is important to contact the patient s insurance prior to services being rendered. It is poor customer service to bill a patient for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure. Medicare ABN s Providers are responsible for obtaining an ABN prior to providing the service or item to a beneficiary. The form must be filled out in its entirety as well as the cost to the patient and the reason why Medicare may deny the service Only the approved Form CMS-R-131 is valid and the forms may not be altered Nancy Enos Medical Coding AAPC Approved

8 Admission/Registration/Check-in Failure to enter accurate patient identification, demographics or insurance information. The number one reason why most medical billing claims deny is a result of not verifying insurance coverage. Because insurance information can change at anytime, even for regular patients, it is important that the provider verify the member's eligibility each and every time services are provided. Nancy Enos Medical Coding AAPC Approved

9 Admission/Registration/Check-in Primary Insurance When a patient has dual coverage (both parents or both spouses) For Children, the first coverage is the parent with the first birthday in the calendar year (birthday rule) For Insured person, their own insurance is primary and their spouses insurance is secondary When there is a third party liability Injury such as a motor vehicle accident Workers Compensation Nancy Enos Medical Coding AAPC Approved

10 Incorrect patient identifier information The front office staff can help reduce these denials by checking the following details of the patient chart. Name spelled incorrectly Date of birth doesn t match Subscriber number missing or invalid Insured group number missing or invalid Verification of Primary and Secondary payer Nancy Enos Medical Coding AAPC Approved

11 Crossover Claims After the primary insurance has paid Send the primary EOB with the secondary claim Be aware of filing limits Nancy Enos Medical Coding AAPC Approved

12 Clinical Failure to enter accurate information based on physician orders, medical history or medical necessity requirements. Many times this information is inaccurate due to misinterpretation or incomplete information documented. Sometimes the physician only documents the basic information when more specific information is necessary and someone may assume what he/she means instead of asking. Relying on previous notes is a common mistake This can cause conflicting information on the claim that could cause the claim to pay inaccurately or not at all. Nancy Enos Medical Coding AAPC Approved

13 Coding Coding claims accurately lets the insurance payer know the symptoms, illness or injury of the patient and the method of treatment performed by the physician. ICD-10 codes that are unspecified are often denied Coding mistakes occur when the claim is submitted to the insurance company with the wrong diagnosis or procedure code or modifier on the claim. Medical Necessity Linkage This may cause the claim to deny for reasons such as no medical necessity or procedure does not match Nancy Enos Medical Coding AAPC Approved authorization

14 ICD-10 Coding Your claim may be denied because your provider s diagnosis needed to be more specific. Set up electronic prompts into your charge capture system that alert the user when there is a more detailed code available. ICD-10 Guidelines include instructions on sequencing codes, and using cause and manifestation codes Follow code also and code first instructions Status codes (Z codes) are not always payable as a primary diagnosis Nancy Enos Medical Coding AAPC Approved

15 Medical Necessity Linkage Each claim line contains a CPT or HCPCS code (describing the service) and ICD-10 code(s) providing the reason for the service. These 2 code pairs must link. Z for a preventative visit, and ICD-10-CM codes describing symptoms or diseases for E/M problem visit codes. Nancy Enos Medical Coding AAPC Approved

16 Timely Filing Limits Many payers have filing limits It is essential to confirm who is responsible (coordination of benefits) for a claim to avoid misdirected claims Keep records of claims submissions to appeal Be aware of filing limits for each payer Nancy Enos Medical Coding AAPC Approved

17 Modifiers Modifiers provide additional explanation of a circumstance where a HCPCS code should be paid when it otherwise would be denied. Modifiers 24, 25 and 57 append to E/M codes only. Be careful about adding modifiers to get a claim paid. Modifiers must represent the true circumstances as documented in the note Nancy Enos Medical Coding AAPC Approved

18 Correct Coding Initiative The mutually exclusive edit table contains edits consisting of two codes (procedures) which cannot reasonably be performed together based on the code definitions or anatomic considerations. Each edit consists of a column 1 and column 2 code. If the two codes of an edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a CCI-associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed Nancy Enos Medical Coding AAPC Approved

19 Can medical claims denials be avoided? Tracking the types of denials you receive will benefit your practice by allowing you to pinpoint cause Front office Eligibility Non-covered services Clinical Complete documentation Medical necessity must be demonstrated Back office Credentialing- be proactive in provider enrollment before rendering services Sending out scrubbed claims to maximize first-submission payments Approved

20 What steps can I take to correct a claim? Once a claim is denied, investigate the cause Missing and incorrect information-update and resubmit Track and give feedback Demographics track and hold the front desk accountable Missing Clinical information- review note with the clinician and resolve Coding and Billing errors- billing staff should research and correct, use the denial for educational purpose Approved

21 Denial Trends Implement a standard for posting denial transactions This will allow for reporting trends include the payer, procedure and reason Drill down into the payer to learn more about their unique rules Review written off denials often Approved

22 Why don t payers follow the CPT Guidelines? HIPAA included a provision for Uniform Code Sets Covered entities use CPT (Current Procedural Terminology) ICD-10-CM (International Classification of Diseases) HCPCS (Healthcare Common Procedural System) Private and Commercial Payers accept these codes, but have contracts and varying levels of coverage, in order to provide insurance policies that are competitive Signing a contract with a payer requires a practice to abide by their coverage policies Approved

23 Parting Thoughts The revenue cycle has many touch points where claim denials can begin Use tools to verify clean data from beginning to end Use denials to create insurance specific rules when payment policies change Utilize electronic scrubbers to embed rules, instead of relying on training Monitor denial trends to stay ahead of downward trends Approved

24 Resources For more coding information: Visit For denial management ebooks and more: Visit Call (855) Or Approved