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How to Reduce Denials for Otorhinolaryngology Practice?

One of the oldest health practices in US, Otorhinolaryngology deals with the diagnosis and treatment of ailments in not only the ear, nose and throat, but also in other illnesses related to head, neck, larynx (voice box), mouth and sinuses. Medical practitioners specializing in Otorhinolaryngology also perform surgeries which include plastic or reconstructive as they are specialists in facial surgery or sleep medicine. Otorhinolaryngology is also referred to as Otolaryngology or ENT.

Otorhinolaryngology billing and coding can be a complex procedure as the billing is done for surgical procedures as well as office visits. It also gets frustrating to call insurance providers time and again for reimbursements. Thus, here are some ways in which denials can be reduced in this practice:

  1. Codes/Modifiers: Wrong codes or modifiers can result in rejections and denials. Hence it is imperative to code to the highest level of specificity. Coding requires that coders read not just the procedure summary but the entire operative report, as procedures tend to differ. Further, to reduce denials, coders must be aware of the anatomy. For e.g. sinus could be at the frontal, maxillary, sphenoid or the ethmoid regions, hence coders need to code differently for all these sinuses. Coders must be careful while coding for removal of nasal polyps as it is included in surgical codes, but not separately. Coding errors which must be taken care of are also those related to billing cautery of the turbinates, coding for tissue removal etc.
  2. Documentation: Physicians need to document the sinus they have entered or exited thereby allowing the coders to code appropriately. Codes also differ for diagnostic as well as surgical nasal/sinus endoscopy procedures hence the need for precise documentation. Sometimes, coders tend to get confused while coding for maxillary anatomies. For the same, physicians must include/exclude the word ’tissue’ for the maxillary sinus (Tissue includes polyps, fungus ball, mucocele etc.). The physician must hence remove tissue from inside the maxillary sinus, not around its opening. Further, while coding for ostium balloon dilation codes, coders need to look for terms such as ‘dilation’ or ‘displacement.’ For endoscopic sinus surgery, the physician must document as per soft tissue and/or bone removal, not displacement or dilation. If a physician performs a balloon dilation, soft tissue and/or bone removal, coders must report only endoscopic sinus surgery code, not both.
  1. Edits: Medical claim edits are vital. As payers change, healthcare providers must write the edits in patient accounting or claim management software. Further, modifiers must be applied in edits and in clinician’s workflow and moved towards adjudication to obtain clean claims rate.
  2. Denials: Denials can cause a huge drop in revenues. Missed documentation or coding errors lead to denials. The cause of denials must be known quickly in case of rejections and tackled with quickly. It is significant that the claim appeal then must be filed at the earliest possible.
  3. Outsourcing: If denials are increasing, outsourcing can help as the agency’s professional billers and coders are knowledgeable about payers, and can assist in reducing backlogs and underpayments. They are also helpful as they reduce in-house staffing costs. Again, they are updated and informed about codes and modifiers required for apt billing. They are regularly trained and this cost gets reduced for the healthcare provider. They also save time while the medical practitioners can focus on patient care and the administration can assist patients in other matters. Nonetheless it is absolutely essential that outsourcing must be given to the agency which specializes in ENT billing and providers including Medicare, Medicaid and other private payers.

A knowledgeable and dedicated mitigation team in-house or an outsourcing agency can ensure a robust denial free process thereby augmenting revenues.

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