The Smart Medical Practice

Da Nile Ain’t Just a River in Egypt – It’s in Your Medical Practice


Claim DenialsTo make sure that your medical practice avoids denied claims from insurers, it is important to know which claim codes are the most often denied and why these denials occur.

According to ReMatrix, for the period of March 1 through March 31, 2014, the top most common unexpected medical practice denials fell under the following codes:

Five Most Unexpected Denial Reasons All Practices In US March, 2014
CodeDescription
CPT Code 99213Level 3 Outpatient Doctor Visit
CPT Code 99214Level 4 Outpatient Doctor Visit
CPT Code 97110Therapeutic procedure, 1 or more areas, 15 minutes each
CPT Code 36415Routine blood capture
CPT Code 97140Manual therapy techniques (e.g. Manipulation, mobilization, minimal traction, minimal lymphatic drainage, 1 or more areas, 15 minutes each

 

Data for the same period, but only for Internal Medicine Specialists had three of the top five national reasons for denial. In order they are:

Five Most Unexpected Denial Reasons Internal Medicine In US March, 2014
CodeDescription
CPT Code 99214Level 4 Outpatient Doctor Visit
CPT Code 99213Level 3 Outpatient Doctor Visit
CPT Code 99232Subsequent hospital care
CPT Code 36415Routine blood capture
CPT Code 85025Routine blood work

 

Comparing all practice denials to internal medicine denials we see the following:

 

 

Comparison of Unexpected Denial Reasons All Practices vs Internal Medicine, March 2014
RankAll PracticesInternal Medicine
118 – Duplicate Claim18 – Duplicate Claim
297 – Bundled Service97 – Bundled Service
316 – Lack Of Documentation16 – Lack Of Documentation
496 – Non-Covered Benefit109 – Service Not Covered By Carrier
529 – Expired Time Limit96- Non-Covered Benefit

 

For both groups, it seems that the different practice types have much in common as to type of claims denied and the reason for their denial.

The top two claims denied are evaluation and management codes. For all groups the denial is for a level 3 office visit and for internists it is for a level 4 office visit. Regardless of the visit level denied, the overwhelming reason for these denials is denial reason 3 16 – lack of documentation.

With an electronic health record, templates filled out by the physician as he or she renders services help to make sure there is enough documentation to support the visit level chosen by the provider.

Non-covered benefits are another area that brings denials. Proper contract administration and loading into the billing software prevents billing the insurance carrier for non-covered services. While Medicare requires an ABN, other insurances do not. Since almost every provider has every patient sign a financial responsibility form, there is no reason your billing system should fail to bill the patient for non-covered services. Waiting for a denial before billing the patient is a bad idea as you delay your reimbursement and subject your claims to needless scrutiny.

If your medical practice also operates a full or partial clinical laboratory, consider reviewing whether or not to continue the operation of your lab. Lab work is a breeding ground for denials and the reimbursement, when approved, is light.

On a regular operating basis, running monthly denial reports is a great way to understand how your medical practice can collect more income and avoid doing medical procedures for which you are not paid.

Overview of PracticeSuite Medical Billing Software


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