Reducing E/M Services Claim Denials

E/M Services Claim Denial Reasons

As per the Centers for Medicare & Medicaid Services (CMS) data, approximately 15 percent of evaluation and management (E/M) services are improperly paid and accounted for almost 9.3 percent of the overall Medicare fee-for-service improper payment. Some of the common claim denial reasons are ‘similar services from multiple providers in the same group’; ‘Correct Coding Initiative (CCI) inaccurate bundling’; ‘duplicate claim submission’; and ‘inaccurate billing for global surgery’. So, let’s understand these Claim denials & their resolutions to reduce evaluation and management (E/M) services denials.

Common E/M Services Claim Denials

1. Similar Services

One of the common claim denial reasons is ‘similar services from multiple providers in the same group’. You will receive this denial because the payment was already made for the same/similar service(s) within the set time frame. When you receive this denial, first verify that the denial is not based on previous payment information.

To avoid this claim denials, be aware of the following billing tips:

  • Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.
  • When more than one E/M service is provided to the same patient on the same date by more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems.
  • Physicians in the same group practice but who are in different specialties or subspecialties may bill and be paid without regard to their membership in the same.

If the claim needs to be appealed, signed medical documentation should be provided to justify the services that were provided on that date of service. On appeal, the identification of the providers’ subspecialty, when more than one provider from the same group is billing for E/M services to the same patient on the same date, can be helpful in explaining why multiple providers were needed.

2. Inaccurate CCI Bundling

Practices often make mistakes in choosing correct codes resulting in claim denials. Correct Coding Initiative (CCI) is taken by the Centers for Medicare and Medicaid Services (CMS) to develop, promote, and encourage correct coding practices in order to prevent payments that could be given in error. The purpose of the CCI edits is to prevent improper payment when incorrect code combinations are reported. You can check the CCI edits prior to claim submission on the CMS website. These CCI edits are updated quarterly. Conduct internal audits of documentation versus code selections, especially for E/M services.

3. Duplicate Claim Submission

When insurance carriers find you submitted more than one claim for a single service, you will receive remittance advice as, Duplicate Service(s): The same service submitted for the same patient, same date of service by the same doctor will be denied as a duplicate. To avoid this denial, the claim status should be checked to verify that the claim duplication is not based on previous payment information. In most cases, multiple E/M services that are performed on a single date by the same provider must be combined and submitted as a single service.

4. Global Surgery Denials

CMS determines the global days of surgery. As part of the Medicare Physician Fee Schedule database (MPFSDB), the codes all include their global information.  Please check the website for any surgical code that might cause your claim to be denied. The ‘global day’ field on the physician fee schedule will have the information on global day coverage information. For example, if the global days are 90 then major surgery with a 1-day pre-operative period and the 90-day postoperative period is included in the fee schedule amount.

Please note that evaluation and management (E/M) services can be payable according to certain guidelines within a global period. Verification of the post-operative global days for the services provided and the appropriate diagnosis information will help make sure that any action taken to correct the claim will be approved.

To prevent your E/M claims from being denied, CMS recommends a number of strategies. First, in addition to the individual requirements for billing a selected E/M code, you should also consider whether the service is ‘reasonable and necessary.’ For example, while it is possible to provide and document a level 5 office visit for a patient with a common cold and no comorbidities, it is unlikely that anyone would consider that level of service reasonable and necessary under those circumstances.

Another strategy is to consider various factors while choosing the correct codes for E/M services. Key variables when selecting codes for E/M services include patient type (new or established); setting/place of service; and the level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (i.e., the number and type of the key components performed). Finally, the fact sheet emphasizes the need to obtain the necessary physician/non-physician provider signatures.

Medical Billers and Coders (MBC) is a leading revenue cycle company providing complete medical billing services. We can assist you in reducing E/M services claim denials to receive accurate insurance reimbursements for delivered services. To know more about our medical billing and coding services, email us at: info@medicalbillersandcoders.com or call us at 888-357-3226.