Five ways to get your claim processed faster

With Medicare claims processors taking a closer look at each submission to ensure all the i’s are dotted before approving payment, it is more important than ever that providers avoid the most common coding mistakes claim auditors will be on the lookout for, according to Los Angeles-based Conomikes Associates. The five most common claims denials and ways Conomikes recommends to deal with them are:

1. Incomplete patient diagnosis/condition. If you keep your diagnostic codes current, this is also one of the easiest denials to avoid. Most often, claims are denied because they did not include the 5th digit in the patient diagnosis profile, and/or the code was incorrect or outdated.

2. Duplicate claim/service. If you did not submit an already presented claim, it is possible that a service was performed several times on the same day and not billed correctly. To ensure Medicare promptly pays this kind of claim, enter the procedure code only once. Then, in block 24G of the HCFA 1500, indicate the number of units provided. This will protect the claim from being rejected.

3. Not medically necessary. Medical necessity has become a red flag claims checker watch for —and one of the most common items providers fail to fully document. Services can be rejected as not medically necessary for the following reasons: they have been performed too frequently over a specific time period; there is an alternative, less expensive way to treat that particular problem; Medicare considers the procedure experimental or unproven; and, most commonly, the submitted diagnosis does not match the procedure performed.

If certain procedures are associated with frequently rejected claims, check with your local Medicare carrier about its national payment policies for the procedure codes you have been using — plus if there are any billing criteria — frequency limits, specific codes. Finally, review your coding procedures to ensure you are being as specific and correct as possible.

4. Procedures or services not paid separately. Since the national Correct Coding Initiative was introduced, this rejection has become increasingly common. When this happens, you need to recheck your steps. From the original documentation, list all identifiable codes. Next, look up the codes in the Correct Coding Initiative Manual to determine if the service codes are comprehensive or component. Remember, only comprehensive codes can be billed.

Special modifiers -25 (separate E/M on the same date of a procedure) and -59 (significant, separate procedure) can also be used to get payment for separate procedures. Another good move is to send along copies of the original document for the carrier to review.

5. Duplicate of claim now being processed. Time is money. But get in too big a hurry and it could cost you money. In short, allow enough time for your claim to be processed before resubmitting it. On average, electronic Medicare claims are processed in about 14 working days, and paper claims in 27 days. Resubmit your claim before this threshold and it will probably just be rejected.