Denied Claims: 6 Common Reasons and How to Solve Them

Denied claims are a double-whammy: they negatively impact your surgical center’s cash flow, and they also add to your overhead costs because it takes plenty of staff time to correct and resubmit the claims.

During her session at the American Academy of Professional Coders’ HealthCon 2017 meeting, Maggie Fortin, CPC, CPC-H, CHC, taked denials strategy. She outlined some common reasons for denied claims, where they happen, and how to begin to stop them at your facility. This list isn’t exhaustive, but it’s a great place to start. Remember, carriers are sneaky and will suddenly find new reasons to deny your ASC’s claims.

6 Reasons for Denied Claims at Your ASC. Plus, How to Fix Them.

Reason #1

Claim hasn’t identified the correct payer that’s liable for the services—Worker’s comp or Medicare secondary payer, for example.

Look for: Reason code 22.
Look at: Patient Access and Registration.

Reason #2

There is an E/M service reported along with a procedure, but no modifier 25 is reported.

Look for: Reason code 4.
Look at: HIM/coding.

Tip: “Look at the the chargemaster or charge capture processes,” suggests Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS. “Sometimes modifiers are hard-coded in the CDM and/or appended/selected by ancillary department staff,” Goodman adds.

Reason #3

Claim is missing information—for example, an EPO claim might be missing value codes 48 or 49.

Look for: Reason code 16.
Look at: HIM/coding. You might also check Patient Financial Services, says Goodman. Sometimes missing codes may originate from incorrect file maintenance.

Reason #4

Claim has been denied because of another service or procedure performed on the same date.

Look for: Reason code 236.
Look at: HIM/coding, NCCI edits.

Look Out: If you bill two services together that shouldn’t be due to frequency, the payer won’t just deny one and pay the other. Both services will usually be denied, and you’ll need to resubmit just one.

Reason #5

Diagnosis reported did not meet LCD/NCD guidelines.

Look for: Reason Code 50
Look at: Clinical documentation and/or HIM/coding. Correcting diagnosis-related denials may mean educating your physicians—another place where top-notch communication skills will come in handy.

Reason #6

Duplicate billing.

Look for: Reason code 18.
Look at: Patient Financial Services. Billing system may be failing to detect duplicate claims.

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