Responding to Claim Denials - Part 2

In part 1 of this article, we looked at 4 steps to check your billing and coding on denied claims.  Using that information you've checked your coding, your modifiers, your units and your onset dates.  What you submitted meets the generally accepted standards and it was denied!?  It happens every day.  

Most offices don't take the time or have the expertise to appeal denied services.  Insurance companies "bank" on the fact that less that half of denied or bundled claims are ever appealed.  Don't take those denials – get paid for the services you perform!

 #5 - Appeal the decision: Get ready to write! 

Determine the basis for your appeal; incorrectly bundled?  Medical Necessity?  Create an appeal letter that clearly and simply states why this claim should have been paid. Leave your frustration at your office and offer a compelling, fact based, CPT driven reason the claim should be paid. 

#6 – Review the rules for appeal

Review the EOB or the on-line provider resources for the insurance company’s appeal process. Take note of the time frame for receipt of the appeal and the time frame under which the insurance company is required to respond. 

Some carriers require their own appeal form (Blue Cross/Blue Shield, United Healthcare), while others do not.  Keep a copy of the letter/form, documentation you attached, date and address to which the appeal was sent. 

#7 – Appeal the decision.

 Mail the appeal – you can send it certified if you prefer, but document what, where and when you appealed the carrier’s decision.  Be prepared to follow-up if you have not received correspondence or payment regarding your appeal.  Follow-up on these pended claims should begin 4-6 weeks after records are submitted. 


If your office is experiencing a pattern of records requests, a thorough review of your billing practices and documentation might be in order.  For assistance in this and other healthcare related matters, contact us at 888.887.5259.

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Three Areas Impacted by ICD-10

ICD-10 impacts your office in three distinct areas: people, processes and technology.  In order to successfully navigate the changes, let's look at some of the ways I10 will impact your office.


Staff will require training.  Not everyone in your office needs to understand the complexities of I-10, but each person will need to understand a least a little about this coding system. Your front desk personnel will utilize I-10 for pre-certifications and referrals in and out of your clinic.  Staff will need to understand how and what is required under this new environment when they enter new information into your software system.

Your clinic’s billing department will need additional training whether they assign diagnosis coding for you or simply process claims containing these new codes.  They will need to understand the complexities and be ready and able to monitor requests for records, handle appeals and identify trends that impact your cash flow.  Post-implementation, you can expect the need for this expertise to increase as insurance companies process claims more slowly, deny claims more readily and request records more frequently.

The financial management of your office must understand the possible impact of I-10 on the cash flow of your office. They need enough training to assist or manage your billing department when claims are delayed or denied and to facilitate the monitoring of issues and problems post-implementation.  They will need to understand and continue to assess the risks to your practice and know when to implement your risk reduction strategies.

Clinical staff will feel the greatest impact in I-10 as they face the increased scrutiny of medical records documentation.  Understanding the increased documentation requirements for the codes selected is a key element for physicians and other clinical staff members.  Careful consideration of the documentation and code selection pre-implementation can help assure that cash-flow is impacted minimally in the 3rd quarter of 2015 and beyond.


Processes within your office will be significantly impacted by I10.  Revenue cycle processes need to be reviewed and changed. Pre-authorizations, eligibility, charge entry, claims and collection follow-up, and payment posting and denial management all face changes to the processes.  Patient care processes will change as clinical staff will require additional time to document the patient’s condition.  Financial management processes must include monitoring issues, denials and records requests more carefully.


Clinicians may need documentation coaching for improvement and protection of your claim payments.  Paperwork from referrals, superbills, diagnosis “cheat sheets” and more will require review and update. Budget processes will need to be reviewed and modified due to the changes and challenges presented by I-10.


Billing and EHR systems will require updating. Interfaces with outside vendors (payers, clearinghouses, statement processing, etc.) will need to be reviewed and tested.  Changes to templates and/or dictation used to capture documentation may require changes to support the increased need for information.   The use of computer aided coding applications and translation tools to assist your clinical and billing staff may need to be updated, added, tested or changed.

As we prepare for the implementation of ICD-10, we can look to lessons learned from other similar implementations.  For example, in the implementation of the HIPAA 5010 format, although vendors claimed to be ready, there were post go-live adjustments required.  In the migration to a new Medicare contractor, the rules can change and the technology of the payer may not be ready for the new onslaught of charges.  In both instances, cash flow was impacted as everyone scrambled to make corrections and reprocess claims.



Clinical Documentation Improvement Program

Clinical documentation improvement programs are an important piece of the preparation for ICD-10 implementation.  Documentation details why a person seeks care, what care was provided and may be used as defense in malpractice claims and to support the medical necessity of care. 

Each physician’s records must support both the diagnosis and the procedures performed at every visit.  In order to receive reimbursement from a third-party, documentation must be clear and concise.  Vague documentation may results in questions, error and claim denials.

In the current healthcare environment, CPT coding drives reimbursement and many review are focused on whether the procedure codes are supported within the documentation.  With the introduction of ICD-10, there is an increased emphasis placed on diagnoses becoming an important factor in reimbursement decisions. 


Chiropractic reviews frequently cite “insufficient documentation” as a basis for denial.  Focusing on documentation improvement prior to the implementation of ICD-10 will help to reduce denials or assignment of
unspecified codes.  Although there are times when the use of these less-specific codes is appropriate, routine use will result in decreasing reimbursements.  Physicians must take the time to document the specifics to ensure accurate code selection.

A patient’s treatment plan is dictated by the diagnosed condition.  Failure to properly document and assign ICD-10 codes brings increased risk in reimbursement, not only are the initial CPT codes called into question, but the patient’s entire treatment plan may be denied.   

There are several challenges to a clinical documentation improvement program. 

  • Improving documentation without creating excessing administrative burdens and, physician frustration.
  • Identifying the correct details needed, not creating a volume of detail for each visit.
  • Preparing the documentation without encroaching on time spent on patient care.

Physicians have the unique challenge to try and fit the new coding and reimbursement system into their daily clinical workflow without adversely impacting patient care.  Beginning well in advance of ICD-10 is advised.

There are 4 steps to a Clinical Documentation Improvement (CDI) program.

  1.  Assess.  Evaluate the current status of medical records.  Does it support the ICD-9 codes used today?  Will it support ICD-10 code selection?  Does the record support the CPT codes billed?  The outcome of the assessment phase indicates areas of potential improvement for both diagnosis and procedure coding.
  2. Education.  Physician education, training and tools are vital to a successful CDI program.  Training via classroom, webinar, video, or articles can be used to support providers. 
  3. Implementation.  In this step providers and staff work together to support the creation of EHR templates, worksheets and reference tools to make the changes identified in the assessment step.
  4. Maintain.  A CDI program must be maintainable to provide value.  The changes made as a result of the previous steps should be monitored and assessed regularly to ensure that documentation continues to reflect the requirements of the payers as well as federal and state regulations.

The focus of a CDI program should be on increasing the accuracy and completeness of documentation regardless of the impact to the bottom line.  Don’t focus only on the highest dollar services, but on all procedures performed in the clinic.  The most vital role of the CDI program is completely and accurately reporting both diagnosis and procedure codes.

Cornerstone offers Documentation Readiness Assessments and Chart Audits to help you in your CDI program.  The Chart Audit looks at ICD and CPT coding.   Does the information in the chart support the ICD-9 code and have the elements needed to support the CPT codes billed?  The Documentation Readiness Assessment looks specifically at documentation supporting ICD-10 coding.  Based on your documentation today, what ICD-10 code could be assigned and what details, if added, could improve that code assignment.