Coding and Billing

ICD-10 resources for physicians’ practices

The CMS Road to 10 program provides numerous resources to assist physicians’ practices with the transition to ICD-10.

Additional resources


Claims management

The American Medical Association has created a series of interactive online tools on the claims management revenue cycle that includes printable checklists and logs.

AMA claims workflow assistant

AMA CPT Information (CPT is a registered trademark of the AMA)

1997 E&M Documentation Guidelines

1995 E&M Documentation Guidelines

Evaluation and Management Services Guide from CMS.gov

ICD-9-CM Coding Guidelines

National Correct Coding Initiative (NCCI) - Centers for Medicare and Medicaid Services initiative to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.

National Specialty Societies

AMA Heal the Claims Process campaign

Denials

Listed below are examples of some common claim denials with suggestions on the first steps toward resolution.

Coding/Bundling/Modifier Denials - One of the services I reported was denied as “separate payment not allowed when reported with another more comprehensive service/procedure.” According to the National Correct Coding Initiative (NCCI) the codes should be paid separately.

The first thing to do is obtain a copy of the information the health plan used to make the determination in order to prepare an effective appeal. The information may be a reimbursement policy, reference to proprietary bundling databases (ClaimCheck®), newsletters/bulletins, provider manuals, etc. Compare this information to “national standards”, e.g., National Correct Coding Initiative (NCCI) edits, American Medical Association (AMA), special society coding guidelines, etc. There may be information within these resources that will guide you in developing your appeal.

Incorrect Payment Received - I think the health plan paid incorrectly. How can I know for sure?

Understanding the contract agreement and knowing your fee schedule are vital to the proper processing of adjustments. The ability to properly read and interpret the information on the EOB/EOP is a vital step to the accurate reconciling of account. Each message must be reviewed and acted upon as necessary. It is imperative that you understand all messages the health plan is “communicating.” Contact the health plan for a complete explanation and/or clarification of the problem (remember to log the date, time, name of person you speak with and the reference number). Click on the links below to view a few representative examples of plan specific EOB/EOPs and processing messages.

Anthem
Aetna

Lost Claims - Does the health plan have the claim?

The health plan cannot be held accountable for withholding payment if we are not totally confident that the health plan actually received the claim. Clearinghouse and health plan claim acceptance/rejection reports must be reviewed within 24 hours of claim submission. One suggestion for keeping track of outstanding claims is to program your practice management/billing system to generate a report every 45-50 days listing them by the health plan. Contact the health plan for status of these claims. If the health plan has no record of the claim, submit a new claim. Do not automatically resubmit claims without first contacting the health plan or checking online to verify that the claim is nowhere in their system. Many of the “lost claim” complaints we received reveal that the claim was not “lost”. The claim in fact was processed. However, the Explanation Of Benefits/Payments (EOB/EOP) that showed the processing was never received by the practice.

Appeals

What to do if an appeal is denied? Remember to use all levels of appeal available. The health plan’s instructions (even required forms) must be followed to the letter. Failure to follow these instructions may adversely affect a positive outcome. Click on the links below to access some of the health plans’ appeal process.

NOTE: Health plans not listed require providers to access to their secure site to obtain the information.

Aetna

Anthem

CIGNA

Rocky Mountain Health Plans

UHC

The AMA has also developed a helpful brochure to assist you with submitting your appeals. How to Appeal Inappropriate Health Plan Claim Denials.

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