7 Steps for Responding to Denied Claims (Part 1)

It is frustrating to receive correspondence from an insurance carrier bundling, down coding or denying your claims.  Each day offices open correspondence from the insurance companies only to find that some or all of a patient’s services have not been paid as expected.    Some have been placed on hold pending receipt of medical records, others are bundling codes together or just flat denying coverage.

 It’s especially difficult to understand if the insurance company had previously been paying for services.  Some carriers will even pay for subsequent dates, while one or more services are denied pending receipt of the records.  What’s the rationale?  What do you need to do?

#1 Check the Details. 

Why was the claim denied?  Bundled?  Not a covered service?  No coverage?  Medical Necessity?

Review the claim as you submitted it.  Check for the appropriate number of units.  Some codes can’t have more than one unit:  Electrical Stim (97014/G0283) and Mechanical Traction (97012) are both examples of codes where more than one unit is inappropriate.  Some codes with three or more units may trigger a review for some carriers:  Massage (97124) and Manual Therapy (97140) are examples of codes that may be billed with multiple units, but may cause a records request.  These codes will generally be approved when medical necessity is shown and the codes are appropriately documented in the medical records. 

 No coverage?  Talk to your patient!  Do you have the right insurance? 

 Not a covered service?  Check your verification of benefits!  If it should have been covered, keep going! 

 #2 Review the modifiers applied.

If a chiropractic manipulation was performed on the same day as an exam or re-exam, was the modifier –25 applied to the E&M code?  Is the modifier –59 required on one or more of the therapy codes billed?  CPT codes of 97112, 97140 and 97124 may require the use of this modifier.  Some areas of therapy must be outside the area(s) being adjusted.  Before you add the modifier and resubmit, make sure the records support the use of the modifier.

 #3 – Is it correctly coded?

Do the diagnosis listed on the claim support the regions of your CMT?  If you are adjusting 3-4 regions and diagnosing only 1 region, it may trigger a denial.   

#4 - What story does my claim tell? 

Does the Date of Onset (CMS-1500 box 14) contain a “stale” date?  Is it more than 30-60 days old?  Does it reflect the date of your last re-exam?   It is important to update this field as re-exams are performed and treatment plans are updated.  Onset dates that have aged more than 30-60 days can be a review flag for payors.  The necessity of continued care must be established at each re-exam.  These exams should be performed every 30-45 days or 10-15 visits. 

 If any of these problems exist on the claim in question, update your software to reflect the corrections and create a corrected claim.  If your software does not flag the claim as a corrected claim, please write “CORRECTED CLAIM” on the top of the claim form.


In Part two of this series, we'll look at how to formulate the denial.