Medical Coding denials with solutions

Medical Coding denials CategoriesMedical coding denials solutions in Medical Billing
Experimental denials1) Check which procedure code is denied
2) Check the previous claims to see same procedure code paid. If paid send the claim back for reprocessing.
3) If previously not paid, send the claim to coding review (Take action as per the coders review)
4) If require send an appeal with medical records. If appeal upheld escalate to the client for further action
CPT code denials1) First check EOB/reach out claims department to find out which CPT code is denied.
2) Check if same procedure code is paid previously. If previously paid, then send the claim back for reprocessing
3) If previously not paid, send the claim to coding review for the corrrect procedure code.
Frequency/unit denials1) First check how many units billed
2) Check how many units are allowed as per the patient medical policy.(For example if the code is allowed for only 4 units but you have billed the claim with 5 units, then claim will be denied for frequeny/unit.)
3) Correct and resubmit the claim to insurance as corrected claim as per the patient medical policy.

Note: If suppose units billed as per the medical policy, then call and send the claim back for reprocessing.
Diagnosis Code denials1) First check EOB/reach out claims department to find out which diagnosis code is denied.
2) Check if same diagnosis code is paid previously. If previously paid, then send the claim back for reprocessing
3) If previously not paid, send the claim to coding review for correct diagnosis code.
Medical necessity1) First Check CPT and diagnosis Code combination
2) Next see if the same CPT and diagnosis code is paid. If paid then send the claim back for reprocessing.
3) If not paid, send the claim to coding department for review( Usually they refer LCD(Medicare/Medicaid/Managed care) or patient individual policy website to verify the CPT and dx code combination))
4) If Claim billed correctly, send the claim back for reprocessing(It they disagree appeal the claim with medical records).
5) If Claim billed incorrectly, update the correct code and resubmit the claim as corrected claim.
Inclusive denial1) First check which procedure code is inclusive
2) Next check whether that procedure code is inclusive with the
a) Same claim with other procedure code or
b) Other claim on same date of service or
c) Not on the same claim (Globally inclusive)

Same Claim with other procedure code:
1) First check whether the primary procedure code is paid.
2) Check whether claim billed with any modifier(Correct or not)
3) Append the correct modifier and resubmit the claim as corrected claim.

Other claim on same DOS:
1) Check if the procedure code is same or not
2) Next check whether the Provider is same or not
3) Verify whether correct modifier appended or not

Not on the same claim:
1) First check the application to see any Global surgery code billed and also see what is the global period.
2) Next see if modifier is appended or not.
3) If Modifier not appended, then add the correct modifier and resubmit the claim as corrected claim.

Note: If modifier not allowed, then we need to escalate to client for further action(adjustment).
Age and Gender denials1) First check EOB/claims department and find out whether the CPT or DX code billed is inconsistent with patient age/Gender
2) Next check if previously billed with same CPT or dx code paid or not. If paid send the claim back for reprocessing.
3) If not paid, send the claim to coding review for correct CPT or dx code which is consistent with patient age/gender.
4) Update the correct code and resubmit the claim as corrected claim.
Place of Service denialsFollow the below steps to resolve the denial:
1) Check the ERA/EOB and find out the CPT code denied which is inconsistent with the place of service billed or Reach out claims department and find out the procedure code which is inconsistent with the place of service.
2) Check the software application whether previously same procedure code and place of service paid. If previously paid, then send the claim back for reprocessing.
3) If previously not paid, then send the claim to coding team to review the claim and check the correct CPT and Place of service code.
4) If the claim billed is incorrect as per the coding team, then update the correct CPT and place of service and resubmit the claim as corrected claim.
5) If everything correct but still the insurance company is denying the claim for same, then escalate to the provider for further action.

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