Coding errors accounted for 8.7 percent of improper payments made by Medicare in 2018, which cost over $2.75 billion. To avoid costly denials and potential payback demands, it’s essential to review code guidelines before submitting your claims. If your practice is spending precious hours pursuing appeals, it’s time to get ahead of denials with reliable know-how to fix your claims issues upfront.
We have shared most commonly cited reasons for claim denials and lay out essential tips to help you reduce your denial rate and preserve your bottom line.
Missing/ Incomplete/ Invalid modifier
The modifier necessary to process the claim correctly is either missing, incomplete, or invalid for the specific procedure and diagnosis indicated on the claim form. You might get denial with reason code CO 4:- The procedure code is inconsistent with the modifier used or a required modifier is missing.
Know the proper use of the CPT modifiers that exist and are appropriate to use for the specific condition or situation. The CPT modifiers are listed in their entirety in Appendix A of the current version of the CPT Manual. You can obtain the CPT manual from the American Medical Association. You should also know that misuse and abuse of modifiers are under the scrutiny of the Office of Inspector General (OIG) and that can result in significant penalties.
Claims submitted are exact duplicates of previous claims submitted. You will receive error code CO 18. Claims are often denied as duplicates for the following reasons:
- The claim was previously processed (i.e., no payment made, allowed amount applied to the deductible on the initial claim). The provider re-files the claim to “correct” it. The second claim submitted is considered a duplicate, as the initial claim was processed correctly.
- The provider automatically re-files the claim to seek payment if the initial claim has not been paid within 30 days.
If the reason for non-payment is in question, call Provider Services to verify the claim’s processing information. Do not re-file a claim until you know a new claim is necessary. Check the claim status before re-filing a new claim; the claim could be pending in the Medicare system for payment or for additional information necessary to complete processing. Again, call Provider Services to check claim status before re-filing.
Two services, same date:
In contrast to the above duplicate billing error, you may receive a denial if a payer bundles a service you performed into another service, considering the payment for the second procedure included in the more significant service.
Every quarter, CCI puts out a list of code pairs that Medicare — and many private payers– follow when they reimburse physician practices. The CCI edits list pairs of CPT and HCPCS codes that payers will not pay on when you bill them together. Medicare applies these edits to services you bill for the same provider, for the same beneficiary, on the same date of service. All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2. Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1 unless the edits permit the use of a modifier associated with CCI.
A “0” indicator means that you cannot unbundle the two codes under any circumstances.
An indicator of “1,” however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate reimbursements, such as a separate encounter on the same date, a separate anatomical site, or a separate indication.
Modifier indicator “9” means the edit no longer applies. The typical example involves CMS deleting an edit retroactively, meaning it’s as if the edit never existed.
Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.