Denial Management the Easy Way

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Denial Management the Easy Way

• Pat Kinsley RT,CPC,RCC
• Coding Compliance Manager
• Suburban Radiologic Consultants, Ltd.
• Minneapolis, Minnesota
• pkinsley_at_subrad.com
• 952-837-9791

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What do you do in your office when you get a
denial?
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Suburban Radiologic Consultants

• 64 Radiologists
• Providing onsite service to 7 hospitals and
  operating 6 free-standing imaging centers. Also
  providing reading services for a number of other
  sites
• Approximate annual revenue of 80M

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This is our team of coders
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SRC Insurance Staff
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What does your billing process look like?
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Flow process for billing imaging procedures at SRC
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Seek and ye shall find

• Know your payer rules
• Check their web site
• Meet with your insurance representatives
  frequently
• Contact customer service with questions
• Get your answers in writing from payers
• Make every effort to bill according to your payer
  rules. This will help to avoid a processing
  denial, i.e.
• Modifier usage
• Unit billing
• Bundling edits (CCI edits)

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What are your payer policies?

• Check the payer web site for medical coverage
  policies i.e. Medicare NCD/or Local LCD, BCBS,
  Cigna, UHC, and many others
• These policies will define the medical necessity
  that needs to be met in order for the imaging
  procedure to be covered. i.e.
• - ICD-9 codes that are covered, other
• inclusive or exclusive language

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Ordering of the Diagnostic Test

• MCM 150.21 defines an order as a communication
  from the
• treating physician/practitioner requesting that a
  diagnostic
• test be performed for a beneficiary.
• An order may include the following forms of
  communication
• A written document signed by the treating
  physician/practitioner, which is hand delivered,
  mailed, or faxed to the testing facility,
• A telephone call by the treating
  physician/practitioner or his/her office to the
  testing facility or
• An electronic email by the treating
  physician/practitioner or his/her office to the
  testing facility.

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What is Medical Necessity?

• As specified in 4317(b) The Balanced Budget Act,
  referring physicians are required to provide
  diagnostic information to the testing entity at
  the time the test is ordered.
• Medicare defines medical necessity as services
  or items reasonable and necessary for the
  diagnosis or treatment of illness or injury or
  to improve the functioning of a malformed body
  area.

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Medical Necessity Contd..

• Even if a service is reasonable and necessary,
  coverage may be limited if the service is
  provided more frequently than allowed under a
  national or local coverage policy or a clinically
  accepted standard of practice.
• Claims for services which are not medically
  necessary will be denied.

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Medical Necessity Contd

• Diagnosis codes form a crucial partnership with
  CPT procedural codes by supporting the medical
  necessity of the procedure or service performed.
• Most payers, including Medicare, use claim
  edits to review claims. These edits ensure
  that payment is made for specific procedure codes
  when provided for a patient with a specific
  diagnosis code or predetermined range of ICD-9
  codes (i.e. McKesson edit software).

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Rules of Assigning a Diagnosis Code

• All orders for imaging studies should include a
  reason for the study being performed.
• Documentation should include a supporting
  diagnosis to the highest level of specificity.
• If the physician has confirmed a diagnosis based
  on test results, use that as your primary DX
  code. One may also assign the signs and symptom
  codes, if necessary, to meet the coverage
  determination.
• If the diagnostic test did not provide a
  diagnosis or was normal, the testing facility or
  interpreting physician must code the signs or
  symptoms that prompted the treating physician to
  order the study.

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and

• Do not code probable, suspected,
  questionable, rule out or working
  diagnosis.
• Linking is an important step in the reimbursement
  process.
• Service or procedure must be reported with a
  diagnosis that supports that specific service.
  If linking of a DX code to a CPT is
  inappropriate, it will be denied.

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MN LCD- MRA
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Prior Authorization Pre-Certification
Requirements

• There has been a huge change in the way we do
  business with the payer requirements regarding
  the High-Tech Imaging Prior Authorization process.

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ABNs Can Help You Get Paid

• The current ABN is available at
  www.cms.hhs.gov/BNI/downloads/CMSR131G.pdf
• Draft ABN also referred to as BNI-Beneficiary
  Notice Initiative
• Comment period ends April 23, 2007, with 30 days
  for review.  New Form is dated June 2007 watch
  for effective date.
• www.cms.hhs.gov/paperworkreductionactof1995
• click on PRA listing on the left side
• Select show only and enter CMS-R-131 (new form)

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ABN Modifier Assignment

• If you obtain an ABN, be sure to report the
  service (CPT code) with the proper modifier
• GA- The provider/ supplier has provided an
  Advanced Beneficiary Notice (ABN) to the patient
  and is on file.
• GY- This item or service is statutorily excluded
  or does not meet the definition of any Medicare
  benefit.
• GZ- The provider or supplier has NOT provided the
  ABN to the patient. No payment will be made but
  might be necessary for a secondary payer.

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Know the Timeliness Requirement for Your Payers
Filing, Denial/Appeal Process
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The Appeal Process Can be Very Complex

• How to Appeal a Claim Determination (example)
• Medicare (WPS-MN, WI, Il, MI)

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Educational Suggestions for a Successful
Insurance and Coding Team

• Medical terminology-pertinent to radiology
• Anatomy
• Explain imaging procedures
• i.e. radiography, CT, US, MRI, interventional
• Concepts of CPT ICD-9 code assignments
• Modifier usage, bilateral/unit billing, global
  periods, frequency limits
• NCCI edits

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Insurance Staff Should Know Your RIS/Billing
Systems

• How to find supporting documentation to appeal a
  claim for payment such as
• Physician order
• Technical exam sheet (encourage technologists in
  you facilities to add any symptoms or complaints
  the patient has that are pertinent to the study)
• Prior auth and pre-certification approval
  documents
• Dictation of the exam

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Determine the Conduit to Your Payer

• Meet with Payer representatives to
• hear new information (i.e. system access)
• ask questions related to policy coverage,
  billing etc.
• present claim issues and discuss how to resolve
  them
• Obtain payer bulletins to stay current with new
  information
• Dont hesitate to have a radiologist contact the
  payer
• Medical Director when there is a coverage issue

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Provide Resources to Staff

• Personal Computer
• Access to payer websites (i.e. policies and
  guidelines, claim status, eligibility, appeal
  process)
• Receive payer bulletins and alerts
• Reference materials such as CPT, ICD-9, medical
  terminology and anatomy books
• NCCI edits
• Provide them a contact in your office who is an
  expert in radiology coding and billing issues

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Steps to Working a Denial

• Based on the denial reason
• Correlate billing with the dictated report to
  assure accuracy of billing (may need a coder to
  review).
• Check payer coverage policy for coverage
  criteria.
• Correct the claim according to the payer rules as
  appropriate.
• You may need to provide supporting documentation
  and send with a written appeal. This may require
  a supporting letter from the ordering physician.
• Submit your appeal within the required timeline.
  The timeline and the process is generally
  different for each payer.
• Refund payer

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Voluntary Refunds

• If you discover that there has been an error in
  billing such as
• over payment due to unbundling services
• billing for services that were not provided
• you should correct that issue with the payer
• Check the payer web site for their specific
  voluntary refund process
• And make prompt payment voluntarily

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Can you eliminate denials? You can probably
reduce them by

• Being proactive seek information from your
  payers regarding your top 10 denials.
• (WPS Medicare will provide this for you by
  taking the Computer Based Training titled
  Duplicate Claims on their web site.) Check your
  local web sites for other provider education
  tools.
• Define your current office practice and your
  claim submission process
• Educate staff
• Set expectations of staff

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• Maintain a good working relationship with the
• payer representatives.
• Conduct internal audits on your claims. (i.e.,
  physician audits, coder audits, payment analysis)
• External audits, such as the post payment audit
  requests from
• CERT (Medicare)
• Other payer senior products (Medica Medicare
  Solutions)
• And soon the Medicaid review PERM

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If you dont pay attention to your errors,
someone else will.

• Those individuals will be
• Medicare
• Medicaid
• And/or the OIG (Office of Inspector General)
• Currently, we have patients and other payers
• questioning services and billings. Pay attention
  to these situations - you can find underlying
  issues.

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Remember Clean Claims are Paid Claims!

• Claim Scrubbers How can they help in this
  process?
• Identify potential issues prior to claim
  submission.
• This allows you to fix the claim and hopefully
  get it paid in a timely manner.
• These vendors interface with your billing system
  and it scrubs the billing data against criteria
  you have set
• Age, current CPT, ICD-9 for DOS, Modifier usage,
  medical necessity, CCI edits
• This process if generally NOT cost prohibitive
  for a practice.

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Denial Examples

• Case 1
• 74185 MRA Abdomen
• Clinical Hx Severe Hypertension 401.9
• Medicare denial for medical necessity
• Denial Follow-up
• Dictation No obvious stenosis was seen in the
  renal arteries.
• Medical necessity is only Severe Hypertension
• There is a LCD coverage policy on MRA and 401.9
  (HTN is not a covered reason).
• Action Write off

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• Case 2
• HealthPartners denial on the same DOS
• Lumbar Spine 2-3 vw. AP Lateral Interoperative
  1102 am coded 72100 (pd)
• L-spine 1 vw. Interoperative 1235 pm 72020
• (denied procedure was included in paid charges)
• Report Lateral localization vw. shows hemostat
  to probe over the spinous process of L4 .
• This is an inter operative film. It then would
  count as part of the interoperative films
  totaling 3vws.
• Lumbar spine 2-3 vw. Post operative 1253 pm
  72100-76
• (denied code can only be billed once per date of
  service) .
• Denial follow-up
• Dictated reports support these 3 exams. However,
  the lateral vw, and the AP Lat
• Interoperative should be counted together 3 vw.
  L Spine 72100.
• Proper coding
• 72100 3 Vw. Interoperative films
• 72100-76 Post Operative films

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• Case 3
• DOS 02/26/07
• Order Pelvis and lateral both hips
• Hips bilateral minimum 2 vws. Each hip plus AP
  Pelvis 73520-26 (pd)
• Pelvis 72170-26 (denied)
• Lumbar spine 2-3 vw. 72100-26 (pd)
• Denial Follow up
• Order Pelvis and lateral both hips
• Dictation support Pelvis, lateral of Rt. Lt.
  Hips, L spine 73520
• The Pelvis view is included in the CPT
  description of 73520 and therefore, should not
  have been billed as a separate procedure.

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• Case 4
• DOS 02/28/07 Pt. age is 62 yrs. (sometimes on
  peds. comparison vws. are performed. It would
  only be appropriate to bill for services that
  meet medical necessity)
• Wrist 3 vw.73110 RT (pd)
• Wrist 3 vw.73110 LT (pd)
• Wrist 2 vw.73100LT, 76 (Denied as global to
  73110)
• Denial Follow up 3 separate orders and
  dictations
• -Rt. Wrist, -LT. Wrist, -Navicular Vws. LT wrist
• Clinical Indication Wrist Pain, fall
• Coding correction
• 73100 LT, 59 assignment of the 76 modifier was
  incorrect as it was not a repeated service on the
  same day

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Bilateral Billing Rule

• The usual payment adjustment for bilateral
  procedures does not apply. If the procedure is
  reported with modifier -50 or is reported for
  both sides on the same day by any other means
  (e.g., with RT and LT modifiers or with a 2 in
  the units field), base the payment for each side
  or organ or site of a paired organ on the lower
  of (a) the actual charge for each side or (b)
  100 of the fee schedule amount for each side. If
  the procedure is reported as a bilateral
  procedure and with other procedure codes on the
  same day, determine the fee schedule amount for a
  bilateral procedure before applying any multiple
  procedure rules. Services in this category are
  generally radiology procedures or other
  diagnostic tests which are not subject to the
  special payment rules for other bilateral
  surgeries. 

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• Case 5
• Exam Myelogram Cervical, Thoracic and Lumbar
  Spine
• (Global billing from Imaging Center)
• Clinical History Previous cervical spine
  injury. Left-sided numbness. Lower thoracic disc
  abnormality. Using sterile technique a 22 gauge
  needle was placed into the thecal sac using a
  posterior approach at L2-3. 10 cc of Omnipaque
  300 were injected intrathecally. Multiple spot
  films. No initial complication. FINDINGS
  There is some central stenosis at L4-5. There is
  a moderately prominent impression on the left
  thecal sac centered around T11-12. This
  presumably represents disc herniation. There is
  prominent degenerative disc disease at C3-4 with
  retrolisthesis. There is mild retrolisthesis at
  L3-4 and L4-5. CT dictated separately.

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• Billed as
• 72240 C-Myelo, 72255 T-Myelo, 72265 L-Myelo,
• 62284, 62284, 62284 (Injection procedure for
  myelography and/or computed tomography, spinal
  (other than C1-C2 and posterior fossa)
• Medicare Denial Reason-
• Bundled (72240, 72255, 72265)
• Duplicate-62284, 62284, 62284
• Denial Follow-up
• Remove 2-62284 only one injection was performed.
• The three separate SI codes are inclusive of
  72270. Therefore remove 72240, 72255, 72265 and
  replace with 72270- Myelography, two or more
  regions (eg, lumbar/thoracic, cervical/thoracic,
  lumbar/cervical, lumbar/thoracic/cervical), RSI

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Global period edits

• Case 6
• Billed as 36578, 77001
• On 02/10/07 patient returns for replacement of
  the tunneled line port catheter under fluoro
  guidance due to a device related problem
• Denial Reason- Bundled 36578 77001
• Denial Follow-up
• Insertion of a tunneled central venous line with
  port Fluoro 36561 77001(10 day global) on
  02/02/07
• 36578 Replacement would require the addition of
  modifier -78 (Return to the OR for a related
  procedure during the post op period)
• The 77001 would not require a modifier to be
  assigned as it is an (add on code)

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Global period edits

• Case 7
• Billed as G-tube placement 43750, 74350 on
  3-02-07
• Denial Reason Bundled 43750
• Denial Follow-up
• PICC placement with fluoro guidance 36569
  77001 performed on 2-26-07 (10 day global)
• 43750 would require the addition of modifier -79
  (Return to the OR for a unrelated procedure
  during the post op period)
• The G tube placement was UNRELATED to the PICC
  placement