Claim problems bugging you? You can avoid them

Tips from HCFA and the experts

Based on studies from the Health Care Finan cing Administration and interviews with coding experts, here is a list of the most common reasons reviewers give for denying Medicare claims — and what you can do to avoid them.

Incomplete/poorly documented diagnosis.

Perhaps the most common denial and the easiest-to-fix coding oversight is using the wrong diagnosis code or not enough documentation to support the code. To avoid having your claim kicked out for review, be sure the coding paperwork is specific, complete, and current.

Duplicate claim/service.

Failing to bill correctly for services performed multiple times on the same date of service is likely to get your bill labeled a duplicative claim and dumped in the denied pile. To avoid that occurrence when you have multiple same-date services, enter the service procedure code just once, then note in block 24G of the HCFA 1500 the number of units provided.

Resubmitting claims too quickly.

Many carriers wait at least 14 days to process electronic claims; 27 days for paper claims. If you are getting a lot of claims kicked back for being duplications, check your software for glitches.

Service not medically necessary.

Medicare looks for several criteria to determine if a service is medically necessary. The most common reason claims are denied for lack of medical necessity is that the official diagnosis does not support the treatment provided. Auditors also look for unusually high numbers of similar or other procedures performed during a short period of time, higher-priced treatments when obvious and equally effective alternative approaches are available, and procedures Medicare considers to be experimental and unproved.

Not a separately billable service.

When Medicare rejects a claim because it says the service or procedure cannot be paid separately, the most likely cause is a modifier problem. When that happens, check all the codes used against the Correct Coding Initiative Manual to determine if they are for comprehensive or component codes; a component code is part of a comprehensive one. If it turns out they are component codes, then you can only bill for the comprehensive code(s).

Where justified, you can to use modifiers -25 (separate evaluation and management on same date of a procedure) and -59 (significant, separate procedure) to justify a separate payment. But be sure the diagnosis and accompanying documentation support the claim that they were separately performed services.

Wrong physician’s name and/or unique personal identification number.

One of the standard checks on any claim before it leaves the office should be who referred the patient. An easy way to get that information into your system is to design registration forms so patients can write down the physician who referred them, then enter that information in the patients’ electronic files. For charge slips, include a block where the physician seeing the patient can note the referring provider. When there is no referring physician, make sure to list the treating physician’s name and his or her ID number on the claim.

To avoid problems with mismatching physician identification numbers, regularly check to ensure all necessary physician ID numbers are correct, for both the group and each individual provider. Also, make sure new physicians apply for a number before you start submitting claims for their services.

Medicare is not the primary payer.

Federal auditors are now paying extra attention to this area. Therefore, it is vital that your records accurately reflect each Medicare patient’s present employment/retirement situation and third-party coverage. If your records are right, along with your response, have the patient contact Medicare to update the file.

It is also a good idea to ask each time patients come in if they have joined a new health plan since their last visit. If so, get their member numbers and research their coverage.

Finally, it may sound simple, but regularly check to see if you have the patient’s correct Social Security number on file. For best results when submitting a claim, include a copy of the patient’s Medicare card, and if they have a supplemental carrier, that card, too. Make sure the claim contains the patient’s correct ID number and that the patient’s name is written as it appears in his or her Medicare file.