When the HITECH act was first introduced in 2009, it seemed like a really good deal for eligible providers who could buy the latest technology and get incentivized richly to do it. Dare we say completely offset the cost of adoption? Four years later, the stark realities of adoption are coming forth. The table below…
In the recent AAPC article “Know When to Report Excision or Repair (or Both),” the coding rules for performing excisions and repairs for both malignant and benign lesions are described. The following decision tree provides guidance on when it is appropriate to report repairs separately (per AAPC): Is it a simple repair (e.g., involving “primarily…
In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar with their…
In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar…
So, how do you create a Closed Loop Denial Prevention Process? It requires a rules engine capable of finding claims that are destined for denial; preferably before they are posted to the PM system so that backend modifications and corrections are not needed and without creating a lag time prior to submission with negative cash flow impact.
With AccelaSMART, White Plume clients use their denials experience and payor communications to proactively set up customized rules. These rules are designed to prevent denials and improve 1st Pass Pay rates (the rate at which claims are paid with the first submission). The customization available within AccelaSMART allows users to set up the specific criterion that applies to their services, coding, master files, providers, region, plans and other details about a specific claim to ensure it will pass the payor’s edits. Think you don’t need that much granularity? Remember, United Healthcare applies over 82,000 rules to adjudicate claims over and above the industry standards. Think about that.
Diagram 1 depicts a Closed Loop Denial Prevention Process, starting with the advent of a new policy or denied claim, building a customized rule to catch conditions that will trigger a denial, enabling the rule for all billers to use and thereby preventing the denial from happening again.
The great thing about a Closed Loop Denial Prevention Process is that it is scalable and uniform across an organization. The process can be applied consistently for each biller, regardless of their experience, skill sets and day-to-day distractions. It improves productivity with workflow designed to minimize errors and streamline corrections. Using a closed loop process significantly reduces the time clinicians spend on getting claims paid and puts process improvement at the right point in the life cycle of a charge.
Ultimately, a Closed Loop Denial Prevention Process improves cash flows and profitability by ensuring claims can be paid as they should be, quickly and completely.
- Closed loop; noun – a control system with a feedback loop that is active
- Denial; noun – the refusal to satisfy a claim, request, desire, etc.
- Prevention; noun – an action that stops something from happening
- Process; noun – a systematic series of actions directed to some end
As the name implies, a Closed Loop Denial Prevention Process is one designed to prevent denied claims. This process uses a system of rules and edits to provide consistent feedback that is dynamically available each time conditions are present that will result in a denied claim. The process alerts users to the potentiality of the denial and instructs modifications that will prevent the denial from occurring.
Beats the heck out of sticky notes.
Even if they have never thought about the term closed loop denial prevention, this is a process that White Plume users know well. They’ve most certainly been keenly aware that AccelaSMART™ is a dynamic, interactive method of finding potential denials and fixing them prior to creating charges and submitting claims.
So how do you actually prevent denials through a closed loop denial prevention process? Stay tuned…
When physicians perform multiple surgical procedures on a patient during the same session, certain rules must be applied in order to code the claim correctly. Claims must be reviewed to make sure the codes are reported in compliance with bundling rules, National Correct Coding Initiative (NCCI) edits, and relative value units (RVUs). Code Order Matters…
When physicians perform multiple surgical procedures on a patient during the same session, certain rules must be applied in order to code the claim correctly. Claims must be reviewed to make sure the codes are reported in compliance with bundling rules, National Correct Coding Initiative (NCCI) edits, and relative value units (RVUs).
Code Order Matters
Surgeons are paid at 100% of the fee schedule for the primary surgical procedure, and at 50% for all subsequent surgical procedures performed during the same surgical session. As such, the procedure with the highest RVU should always be listed first. The Medicare Physician Fee Scheduled Database (MPFSDB) lists the RVU value for each surgical CPT® or HCPCS code. The MPFSDB is updated annually, and the current version is located on The Centers for Medicare & Medicaid Services (CMS) website.
If a surgical code with a lower RVU value is listed as the primary surgical procedure on the claim, insurance companies will pay the claim at the lower RVU rate—leading to a lower reimbursement rate.
Current Clients: White Plume’s AccelaSMART product offers Procedure Sequencing at the click of a button, relieving pressure on the billing staff to remember the RVU of all procedures.
Watch out for Unbundling
CMS developed the National Correct Coding Initiative (NCCI) to prevent invalid code combinations from being paid. NCCI edits are classified into two major categories:
- Column 1/Column 2 Edits (Status 0) – Code pairs that are not normally reported together because one of the procedures is already considered a component of the other procedure
- Mutually Exclusive Edits (Status 1) – Code pairs that are not reasonably performed together in the same operative session for anatomic reasons
Code pairs with a status indicator of 0 cannot use modifiers to override the NCCI edits. However, code pairs with status indicator of 1 can use certain modifiers to bypass an NCCI edit, when used appropriately. These modifiers include the following:
- Anatomic modifiers: E1-E4, FA-F9, TA-T9, LT, RT
- Coronary artery modifiers: LC, LD, RC
- Global surgery modifiers: 58, 78, 79
- Other modifiers: 59
Click here to access a list of NCCI edits.
Current Clients: The AccelaSMART validation product contains the NCCI edits including “Status 0” verses “Status 1” information. If a code pairing violates bundling edits, our messages will tell you if the pair accepts a modifier for correction or not. The message even suggests the appropriate modifier. The user does not have to research the pair!
Modifier 59 is often used to report subsequent procedures that are separate and distinct from the primary procedure. The criterion for “separate and distinct” means that the procedure was performed:
- During a different operative session
- On a different organ
- On a different incision or excision
- For a different injury or lesion
Current Clients: The AccelaSMART validation engine alerts users when a Modifier 50 is acceptable and suggest review of documentation to ensure it is a valid submission for the encounter.
White Plume offered its first ever “5.0 Rule-Building Lab” in February. In this two hour WebEx session, clients on AccelaSMART 5.0 and higher gathered to ask questions, learn more and share successes of using the powerful and flexible rule builder found in AccelaSMART.
100% of the participants reported they would suggest the lab to a colleague.
Many thanks to the clients who participated and for the excellent examples and feedback they provided which helped make the session a success. The response was extremely favorable and White Plume is looking forward to offering similar sessions in the future. If you are interested in being notified of upcoming sessions, you can email firstname.lastname@example.org.
Providers are fighting to be reimbursed for every dollar. Getting reimbursed properly requires back office staffs to diligently pay attention to changes in payor rules.
Barriers to Proper Reimbursement
It is not unusual to hear horror stories from billers regarding denials by payors. Some private payors appear to deny all claims the first time they are submitted, even if the claims are documented correctly. Other problems may involve payors changing the rules so frequently that a service which pays one month may be denied in the next. Lastly, when billers attempt to resolve claim errors, insurance companies may be less than helpful, telling billers they “ought to know” what to do.
What Can Be Done
“A Dozen Steps to Successfully Appeal Denied Claims” on Codapedia, the free encyclopedia for Medical Reimbursement, makes the recommendation of auditing the insurance payor trends to see if they are consistent with the contract. If the practice got a “good deal” on the payment rate but the payor has provided a high denial rate, the difference in the payment rate and the amount actually paid after adjudicating claims may not be a very good deal after all.
Some additional suggestions:
- Understand why the claim was denied. In some cases, the reason for denial is too generic for the provider to interpret, so practices resubmit claims repeatedly until they find the magic combination. Understand early.
- Follow the insurance company’s rules. Update your sticky notes or customizable code scrubbing software as often as insurance companies update their requirements.
- Make a compelling case. Use professional language and reference key publications, including copies of selected passages in your claim to support your case,
- Confirm receipt. Follow up on your claim submissions by calling and emailing the recipient.
- Set boundaries. Some claims may cost more to resubmit than you would receive.
- Compile appeals. Present multiple denials for consideration at the same time.
- Maintain a hassle folder for each company. Organize your denied claims by dollar and type.
The author is right by saying, “Preventing denied claims is a key skill of successful billers. But getting some denials will always be a fact of life in today’s complicated physician payment system. Appealing denials is your right: it pays to exercise it.” Billers must fight for every dollar, but in many cases, the fight pays off.
For information on customizable code scrubbing software that can decrease your practice’s denials, contact us.