CPT copyright 2015 American Medical Association. All rights reserved. YOUR CODING TOOLKIT ||||||||||| 417 Appendix B I. Know How and Why to Appeal Inappropriate Health Plan Claim Denials, continued 6. Evaluate the health plan’s explanation of benefits (EOB) for accuracy (eg, potential processing errors, lack of recognition of a CPT modifier, incorrect Physician Fee Schedule). 7. Know your contracted fee schedule rate with each health plan for procedures and services commonly performed in your practice. Review each EOB you receive to ensure the negotiated payment and discount rate with each health plan is calculated appropriately. 8. Maintain a health plan follow-up log that contains the reason that the claim was partially paid, delayed, or denied by the health plan and also the internal follow-up action by practice staff to reduce future health plan underpayments and denials. 9. When submitting a formal claim appeal letter to a health plan, thoroughly explain your rationale for chal- lenging the health plan’s claim denial. Additionally, include the appropriate documentation to support your request to reverse the denial. 10. Streamline your practice’s claim auditing and appeals processes by maintaining an appeals resource file with appeal template letters, rationales, and supporting documentation of previously submitted claim appeal letters that resulted in overturning the denial. 11. Keep on appealing. It may take more than one appeal to reverse a health plan’s incorrect denial. When a procedure or service has been appropriately performed, documented, and reported, be per- sistent to ensure your practice obtains the proper compensation based on the negotiated health plan contracted rate. 12. If the appeal is not overturned by the health plan after appeals are exhausted, file for an external review if available through the appropriate state or federal regulatory agency. © 2006 American Medical Association CPT is a registered trademark of the American Medical Association. All rights reserved. II. Supporting Your Appeals for Payment Filing appeals using these suggestions makes the payer aware that the physician is knowledgeable of coding guidelines and adheres to coding conventions. Include a quote from the current coding guidelines that is applicable to the billed service. Example: “According to Current Procedural Terminology (CPT®), modifier 25 is used to identify a ‘significant, sepa- rately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.’ See the American Medical Association publication CPT® 2015, Professional Edition.” Note where a denial is in conflict with the payer’s written policy, quoting from its policies and procedures manual. Example: “According to Section xxx.x of your Professional Services Manual dated July 1, 2013, your policy is to follow National Correct Coding Initiative (NCCI) edits in your claim adjudication process.” Quote NCCI edits reflecting correct coding and/or use of modifiers. Example: “According to Version xxx of the Centers for Medicare & Medicaid Services NCCI edits, there is no edit that pairs CPT code 69210 (removal of cerumen) with an E/M service. The E/M service was necessary to diagnose otitis media, and the removal of cerumen was medically indicated because the patient had impacted cerumen. The reported diagnoses were linked to the appropriate service performed and billed.” Include as appropriate any operative and/or procedure notes. Highlight the procedures that relate to the codes. If a problem is recurring, suggest to the insurer ways it can be avoided in the future. Frame the proposed resolution in a way that enhances quality, access, value, and cost-effectiveness to patients, the payer, and the practice.
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