December 22, 2015
Revenue Cycle 4: Winning Appeals

We now know that, in the first four weeks of ICD-10, 10.1% of claims filed under ICD-10 were denied, according to the Centers for Medicare and Medicaid Services (CMS). Although it’s only slightly higher than the historic normal denial rate of 10%, the flexibility in coding specificity that is being extended to hospitals and facilities has probably kept the denial rate artificially low.

As specificity requirements increase to the levels prescribed by the ICD-10 coding vocabulary, denials may begin to pile up. To make the transition a success, it’s going to be important to quickly and effectively have denials adjudicated and paid. Here’s what you need to know.

Bulking up the coding and billing department

According to a recent survey, 75% of hospitals and facilities anticipated a 30% drop-off in coder productivity due to ICD-10, but only 34% planned to make up for the loss by either hiring new coders or expanding relationships with external providers. Furthermore, just 28% said they planned to use both approaches to ensure coder productivity remained steady.

This could be financially fatal, especially when you consider that two-thirds of survey respondents reported having 10 or fewer coder personnel. In these situations, the loss of a single coder due to normal turnover of staff, coupled with decreased productivity for the rest of the team, could put incoming revenues on the brink. Even where coding staffs number 11–30 individuals (22%) or 30 or more (13%), expected lost productivity could equate to up to 9 or more lost personnel.

If you can’t add staff in the back office, perhaps it’s time to think about the exam room. Real-time coding, performed at the point of service by providers fully trained in and expert with ICD-10, can help ensure the right level of detail is recorded, to guide your back-office coding and billing staff in creating valid codes and submitting clean claims in the first place.

Making documentation do more

Your electronic health record (EHR) system should be chock-full of the documentation needed for coding claims and winning appeals. According to the survey, 70% of respondents are formally attempting clinical documentation improvement programs, and yet 70% are not using the technology itself to achieve these improvements.

To meet the specificity and burden of proof required by the ICD-10 code set, detailed documentation is a must. Each patient record must contain all the information needed to verify the case history, need of service documentation, procedure documentation and patient medication history. Your best answer to any denial is to provide clear, concise and thorough documentation. Using medical scribes to record the patient encounter as it happens frees up the physician to elicit the required of level of detail, while simultaneously ensuring that those details are recorded for coding evidence. Remember: If something wasn’t recorded, it wasn’t done.

Appealing a denial

First, figure out the reason or reasons the claim was denied — lack of specificity or an incorrect modifier, for example. When going back through the documentation to make the correction on the amended claim, try to spot where or how the error occurred. The patient’s name may have been misspelled, the right-side modifier may have been used instead of bilateral, the wrong insurance carrier may have been billed — there are any number of reasons, and knowing the source of the errors lets you put safeguards into place.

Payer requirements will vary, so it may be helpful to create a cheatsheet that lists denial documentation for each payer, and distribute it to all coding and billing staff. Once you’ve amended the claim and compiled the supporting documentation that will be required to overturn the denial, resubmit as soon as possible. Document the submission, including the electronic claim receipt in the patient’s file.

You may run into more problems if the reason for denial was that the initial filing was not timely — it was delayed for one reason or another, and submitted outside the payer’s required time frame after provision of service. Here is where maintaining personal relationships with your payer representatives is absolutely critical: It’s time to get on the phone. Document the reason the claim was not timely and submit the explanation, but speak to the rep, and see if he or she can help. This approach might work, it might not — but it’s your best shot. If you don’t win, it’s one to chalk up to experience.