Wednesday, December 3, 2014

How to avoid an Appeal - part 1



•    Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.

•    Become familiar with Local Coverage Determinations (LCD).

•    Become familiar with National Coverage Determinations (NCD).

•    Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.

•    Document a repeat or duplicate service to reflect it is a distinct and separate service. Failure to document a repeat or duplicate service will result in a denial.

•    Submit supporting documentation with the claim when certain modifiers e.g. 52 or 22 are appended to the service or when a LCD or NCD indicates documentation is required. Failure to submit the documentation will result in a denial.

•    Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.

•    The supporting documentation must include the rendering physician's signature. Failure to provide a valid signature will result in a denial.

•    Enter the concise description of an unlisted procedure code (an NOC code) or a "not otherwise classified" code. Failure to describe the NOC or other scenarios listed below will result in a denial.

•    When Medicare is the secondary payer (MSP) the claim must include information from the primary insurer. Failure to include this information will result in a denial.

Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.

•    NPI of Billing Physician
•    Assignment or Non-assignment of claim
•    Health Insurance Number (HIC) of the beneficiary
•    Zip Code of the place of service
•    All related diagnosis reported with the highest degree of specificity
•    NPI of Referring Physician
•    Date of service
•    Place of service
•    Procedure code
•    Modifiers when applicable
•    Number of service(s)
•    Billed amount for each service
•    NPI of Rendering Physician
•    Clinical Laboratory Improvement Amendment Number (CLIA) for laboratory services
•    The date last seen/X-ray date, initial treatment date for Podiatry, Physical Therapy and Chiropractic services
•    Primary payer data


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