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Managing Insurance Denials

When it comes to getting claims paid, following the 'rules' may not always get the claim paid. In what instances would it be appropriate to ignore basic coding rules so a claim can be paid?

Let me clarify that I am not suggesting you do anything illegal. What I am suggesting is that each insurance company has their own rulebook on processing medical claims and you need to understand what they expect when servicing their insureds and expecting to get paid.

A basic rule of coding states:

When a diagnosis or condition is identified, it should be reported in lieu of the symptom.

What any experienced medical coder and biller will teach you, is that not all insurance companies will pay for a legitimate diagnosis but they may pay for the symptom that caused the patient to seek medical attention.

Example:

The patient is referred to radiology for a CT abdomen/pelvis with contrast. The report states the indications for the ordered procedure is abdominopelvic pain. The findings are ascites. Code selection includes 74177 for the CT and 789.59 for the ascites. The insurance denies the claim for 'diagnosis inconsistent with the service rendered.' What? Why? That is a legitimate diagnosis and reason for ordering the CT scan.

How do you know if the insurance company will pay for a specific diagnosis?

You tend to find out as soon as the claim is denied and you make call to the insurance company for an explanation.

Many insurance companies address covered services in their online information pages. They may also indicate on the explanation of benefits (EOB) in the denial reason that it is a 'noncovered service' or 'invalid diagnosis.'

Keeping a list of services denied for specific diagnoses can help you, as a coder, to begin to search the patient note for more appropriate diagnosis before submitting the claim and avoid denial.

When your claim is denied for an invalid or unacceptable diagnosis, the recommendation is to revisit the documentation to see if another diagnosis is listed that would justify ordering the CT. In the example above, 'abdominopelvic pain (789.09)' was listed as the indication for the procedure and so was ascites (789.59). Change out the diagnosis and resubmit the claim. Bingo! You may find the claim gets paid.

Remember, you have until the contracted timely filing deadline to submit a clean claim, so don't just bill the patient or adjust off the denied service when it is denied. Do a little research, dig a little deeper and try again.

Another example may be as simple as the insurance not covering a CT abdomen/pelvis because the diagnosis is abdominal pain, unspecified (789.00); however, if you revisit the report and can find that the pain was specific to a location in the abdomen ex: upper right quadrant (789.01) or is a generalized abdominal pain (789.07), the claim may be paid.

When you are stumped, call the insurance company. Ask for your representative and explain your situation. You may find that your representative can help you more than you know and if not, that they may be able to refer you to someone who can. Remember, most claims processors are not medical coders and therefore will not give you coding advice, but your representative can help you find the answers you are seeking.

And, as always, search Find-A-Code's library of information first. It may just save you time and money.

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Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.

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