Smart Move: Know These Top Medicare Denial Reasons AND How to Avoid Them

Prevent avoidable Medicare denials!

 

Let’s put data to work to help prevent denials! CGS is one of the Medicare contractors that provides information on top claim denial reasons, and here we’ll take a look at some denial triggers from August 2018 and how you can prevent them.

Check Status Before Reporting Duplicate Service

Reporting the exact same service more than once leads to a duplicate service denial. For August 2018, CGS indicates there were more than 120,000 duplicate service denials for Part B in Kentucky and Ohio.

So how can you avoid this common problem? Here’s what CGS suggests:

  • Don’t resubmit a claim until you’ve checked the status.
  • If you perform the same service multiple times for a patient on the same date, report them on a single claim so additional claims aren’t mistaken for duplicates.
  • Use the correct modifiers (such as bilateral modifier 50 or anatomic modifiers RT and LT) to help tell the story of the service. Be sure to follow the rules of proper reporting to append the right modifiers for the specific case.
  • When you resubmit a rejected service with a new code, don’t include codes from the original claim that were already paid. In other words, suppose you sent in claim A with three line items. You received payment for two, but the payer rejected the third because the CPT® code wasn’t valid. When you resubmit with the corrected code, don’t include the other two items from claim A that you already have payment for.

Bonus tip: This last action point from CGS brings up a reminder we can’t ignore during update season. Prevent rework by keeping your coding resources up to date and using the code that is appropriate and valid for your date of service.

Check Payer Before Submitting Claims

CGS lists two denial reasons that relate to knowing who the appropriate payer is.

First, you may get a denial because the patient is not covered by the payer. To steer clear of this issue, you should check patient eligibility to ensure you have the correct payer. This step may be especially important after open enrollment. As CGS points out, patients may have switched from Medicare to a Medicare Advantage plan.

Second, beware of billing Medicare first when Medicare is the secondary payer. Again, you can check up on patient eligibility to find out if there is another primary payer.

Know What to Expect for Bundled Services

To avoid a denial because payment for one code is included in another code, follow this advice:

  • Check CPT® and HCPCS rules and descriptors for information about whether a code is separately reportable. For instance, the official guidelines for a percutaneous cardiovascular procedure code may indicate that catheterization and radiological supervision related to the procedure are included in the surgical code, so you should not report those separately.
  • Check Correct Coding Initiative (CCI) edits to determine whether Medicare considers the codes to be bundled. The CCI manual provides additional insights into why certain codes are bundled and when you may override the edits to report codes separately.
  • Check the code status on the Medicare Physician Fee Schedule (MPFS). As an example, status B means payment for that code is included in other services.

Expect Some Denials, No Matter What

There are going to be times when proper reporting of codes and following all the rules is going to lead to a denial. As CGS states, even MIPS reporting requirements can lead to denials simply because you’re going to get a message back that the code is for reporting purposes only.

Your organization also may have policies in place to report certain codes that Medicare will deny (such as those B status codes) to help with tracking or to provide evidence via claim that the procedure is being performed.

What About You?

What’s your strategy for avoiding denials? Who on your team handles denials when they do come in?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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