Coding errors accounted for 8.7 percent of improper payments made by Medicare in 2018, which cost over $2.75 billion. To avoid costly denials and potential payback demands, it’s essential to review code guidelines before submitting your claims.
If your practice is spending precious hours pursuing appeals, it’s time to get ahead of denials with reliable know-how to fix your claims issues upfront.
In this post, we look at the most commonly cited reasons for claim denials and lay out essential tips to help you reduce your denial rate and preserve your bottom line.
1. Missing modifier: If you bill Medicare for an E/M service reported with a procedure, but forget to append modifier 25, you may see a denial.
Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is one of the most misunderstood modifiers, so if you ever have doubts about whether you’re using it properly, make sure you follow these rules:
Hint: You do not necessarily need two different diagnosis codes to append modifier 25. While different diagnoses help show the separate nature of the E/M service, they are not required for using modifier 25.
2. Duplicate billing: If your claim looks like a duplicate bill, perhaps due to a forgotten modifier, expect your MAC to deny it.
When you file a claim for multiple instances of a service or procedure, you must include an appropriate modifier to indicate that the service or procedure isn’t a duplicate. The modifier should be added to the second (and subsequent) line items for the repeat service or procedure.
Modifiers that you might need include:
In some cases, though, even when you use an appropriate modifier, your payer may deny the claim as a duplicate based on medically unlikely edits (MUEs). Be sure to check MUEs before submitting your claims.
3. Two services, same date: In contrast to the above duplicate billing error, you may receive a denial if a payer bundles a service you performed into another service, considering the payment for the second procedure included in the more significant service.
Every quarter, CCI puts out a list of code pairs that Medicare — and many private payers– follow when they reimburse physician practices. The CCI edits list pairs of CPT® and HCPCS codes that payers will not pay on when you bill them together. Medicare applies these edits to services you bill for the same provider, for the same beneficiary, on the same date of service.
All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2. Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI.
In certain clinical circumstances, you can override CCI edits and receive separate reimbursement for bundled codes. To find out if you can separately bill services your physician performed, first check the “modifier indicator” on the CCI spreadsheet.
Tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.
Contributing Editor: Kristin Webb-Hollering
Be sure to join us next week for Part 2 as we explore claim errors related to medical necessity. We plan to home in on E/M pitfalls and provide guidance to help you nail down the correct level of service for your E/M services.
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