7 Steps for Responding to Denied Claims (Part 2)

You’ve checked out 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 those 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.


For an example of an appeal letter for the bundling of 98940 and 97140, click here.

#6 – Review the rules for appeal

Review the EOB or the on-line provider resources for the insurance company’s appeal process, noting the timeframe for receipt of the appeal and the timeframe under which they are 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 carriers 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 or click here.


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.

Functional Outcome Measures in Physical Therapy


Beginning January 1, 2013 Medicare requires physical therapist begin reporting functional outcomes on their claims submitted for payment. Medicare and other payers are closely scrutinizing claims for all providers.  This is especially true in the documentation of medical necessity for all physical medicine claims.  The significance of using functional outcome measures has been solidified with this new reporting requirement.


It is more important than ever before to objectively measure outcomes by specific, standardized measures that are used consistently throughout the episode of care.  Repeated use of the same outcome measure at the initial evaluation, each re-evaluation or progress report, and again at discharge allows a provider to clearly demonstrate the medical necessity of the care provided


While the requirement began January 1st, Medicare has provided a transition period from January 1 to June 30 of this year. If you're not properly reporting your outcome measures by July 1, 2013 your claims will be denied.


Medicare has introduced this claims-based data collection strategy to assist in reforming the Medicare payment system for outpatient physical therapy. Medicare will use the data received to determine the need for services, the quality of care, and the value of the service received by the beneficiary.


Similar to the Physician Quality Reporting System (PQRS), functional outcomes are being reported by including additional codes on service lines of the CMS 1500 form (or the electronic equivalent).  The codes utilized begin with the letter G and are commonly referred to as the “G-codes”.  As in PQRS, these can be billed for $0.00 or $0.01 depending on the limitations of your practice management system.


These codes report to Medicare the progress beneficiaries are making towards their goal.  As the initial goals are created, a primary functional limitation is identified, the deficiency measured and the goal established.  For patients where more than one limitation may apply, the provider must make a determination as to the primary functional limitation, as only one can be reported. The therapist may use the limitation that is most clinically relevant to the successful outcome for that patient; the one that would yield the quickest functional progress; or the one that is the greatest priority for the patient. 


The limitation selected should reflect the predominant limitation that the therapy service is intended to address. There are six measures for physical therapists


       Mobility: Walking & Moving Around (PT/OT)

       Changing & Maintaining Body Position (PT/OT)

       Carrying, Moving & Handling Objects (PT/OT)

       Self Care (PT/OT)

       Other PT/OT Primary Functional Limitation (PT/OT)

        Other PT/OT Subsequent Functional Limitation (PT/OT) 


Click here for a printable list of codes and modifiers


Each limitation listed has three codes associated with it. The codes represent the reporting of the projected goal, the current status, and the discharge status. The status is further reported using a modifier to indicate severity and complexity.





0 percent impaired limited or restricted


At least 1 percent but less than 20 percent impaired limited or restricted.


At least 20 percent but less than 40 percent impaired limited or restricted.


At least 40 percent but less than 60 percent impaired limited or restricted.


At least 60 percent but less than 80 percent impaired limited or restricted.


At least 80 percent but less than 100 percent impaired limited or restricted.


100 percent impaired limited or restricted.


When selecting the modifier to use, it should reflect the score from the assessment tool and/or other measurement instruments. If multiple tools are used during the evaluation process, the clinician must combine the results and use sound clinical judgment to determine the limitation percentage. Therapists will need to document how the modifier was determined at the first selection and follow the same process at each assessment interval


Each claim line will indicate the G-code that represents the impairment, a modifier to indicate severity/complexity and a modifier to identify the discipline (i.e. GP = physical therapy, GO = occupational therapy) the date of the service and the billed amount of $0.00 or $0.01.  The application of the KX or 59 modifiers is prohibited.


The functional reporting period introduced by Medicare matches the progress reporting requirement. Beginning in 2013, progress reporting is required at the lesser of every 10th visit or every 30 days.  This means that in addition to the initial visit, an updated status is required at every progress report for current and projected goal with their corresponding modifiers.  At discharge the therapist must report the final status of the patient, again with the corresponding modifier.


What does this change mean for me?


As a provider of outpatient rehabilitation services you must report this information as a condition of payment. This means that your plan of care must contain functional goals related to the disability reported on the claim.  Your goals must be both objective and measurable.


Your documentation must contain the raw scores of the outcome assessment tool used to calculate the score, and clinical rationale behind how you arrived at the modifier value. Your documentation must also include the G–code and modifier you will report on your claims to Medicare


How do I start?


Begin by identifying the functional outcome tools for your practice. There is no one-size-fits-all or single outcome tool that will address all of your patient’s needs. 


Train staff and patients on the importance and use of the outcome assessment tools. Make sure the patient understands what is being asked in the assessment, as the medical necessity of their care will be determined by functional changes reported; make sure your staff understands the importance of that time parameter associated with this recording.


If you haven’t already, begin now to train your office staff to implement the changes necessary to support the reporting of functional outcomes. The functional measures must be supplied at the lesser of every 10 visits or every 30 days. Staff must understand the progress evaluation and coding requirements and work with your software to make sure that the claim generation works correctly.


As with other requirements, establish a review process at the onset to verify and validate the data being reported to Medicare. 


If you need further assistance with this initiative or other requirements, please contact us and we’ll be happy to assist you on your road to compliance.

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