Claim denials can be frustrating, but most are preventable. Below are the top five reasons for denials and how to avoid them.
1. Medical Necessity ICD-10
Why It Happens:
If you assign an ICD-10 code that doesn’t support the testing or interpretation, your claim could be tossed into the denial abyss.
Solution:
Make sure the diagnosis code matches the service. Avoid using preventative or screening codes—they’re just not covered. If the diagnosis isn’t listed in the LCD (Local Coverage Determination) or payer policy, it’s a no-go. Always check your policies and match the codes correctly.
2. Lack of Pre-Authorization
Why It Happens:
No authorization before the service? That’s a surefire way to get hit with a denial letter. Insurance payers are not fans of back-dating authorizations. They want that green light before you proceed.
Solution:
Get your authorization before the service is rendered. If you don’t, you’ll need to adjust the charge or service.
3. Modifier Mischief
Why It Happens:
Assign a modifier incorrectly, and you could face a denial for bundling. But don’t be fooled—sometimes you can submit a reconsideration with notes if it’s bundled incorrectly. And if it’s actually correct, stand your ground!
Solution:
If you didn’t assign the modifier correctly, you’ll need to send a corrected claim or refile with Medicare. Some payers might want notes to back up your claim, so be prepared. It’s all about making sure your modifiers are the right fit.
4. CCI & Frequency Follies
Why It Happens:
Some codes just don’t mix—CPT 99483 and certain other codes don’t play well together. You can’t bill CPT 99483 on the same day as an office visit or other specific codes, and it’s only billable every 180 days.
Solution:
Keep your billing calendar organized and remember that some codes are exclusive party members. They can’t mingle with office visits or other codes on the same day. Always check if the codes you’re using are “allowed” to be together.
5. Documentation Drama
Why It Happens:
For time-based codes like 96136, 96138, and 96132, if you don’t document the time spent, your claim might get denied faster than you can say “missing documentation.” These codes love their paperwork, and if it’s missing, the claim might not even be considered.
Solution:
Make sure your notes clearly show the time spent providing the service. If it’s not documented, it’s as if the service never happened.Remember, CMS allows a range of non-face-to-face activities to meet time requirements, so keep those records tidy and accurate.
Avoiding claim denials can lead to faster payments and fewer headaches. To help prevent denials, please refer to our BrainCheck billing audit checklist.
If you have any questions or need additional support, don’t hesitate to contact our billing specialist.
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