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Managing Medical Necessity: How to turn around denials and get paid<
by: Pamela Moore, PhD
Claim denials are annoying and costly. But denials for medical necessity seem especially frustrating. What do payers know about what is medically necessary? Isn't that the physician's job to decide? Here's the good news. You can reduce medical necessity denials relatively easily. And most medical necessity denials aren't really about a payers saying they think they know better than you. More often than not, it's a matter of sloppy diagnosis coding or billing errors. Code and link accurately Ninety-nine percent of medical necessity denials happen because diagnosis codes (ICD-9 codes) on the claim don't match up with procedural codes (CPT codes), according to Lisa Souba, a consultant with LSA Practice Management and Coding Services in Breckenridge, Colo. "If you think about the CMS 1500," offers consultant Mary Jean Sage, by way of explanation, "you can list up to four different diagnosis codes in Box 21. Then down in Box 24, you list the CPT codes. In line 24E, you bring pointers down from Box 21." The codes in the boxes need to link up. Sage is with The Sage Group in Pismo Beach, Calif. Imagine if you saw a claim that indicated the patient was suffering from an ear infection, but the procedure coded was for an EKG. You'd know right away that something was wrong; that's what payers see, too. Most aren't this obvious, of course, but it is easy for a physician treating a patient with multiple diagnoses to forget to note one. That forces billers to try and guess what to fill in the blanks. "It's pretty amazing what people come up with for diagnoses. The physician knows what he or she is doing, but staff may not code to the highest specificity or may select a code that is altogether inappropriate," says Joan Elfeld, a consultant with Medical Practice Support Services in Denver. Errors also happen because of lack of specificity, says Souba. "Sometimes we'll see where signs and symptoms aren't covered diagnoses for the service, but the actual condition is. The physician[s] won't get specific with their diagnoses." For example, injection of the tendon sheath, CPT 20550, might get denied if paired with ICD-9 code 719.47 for pain in the foot. But it would sail through if paired with 729.4, fascitis. Also, underinformed billing staff may not know which diagnosis or symptom goes with what service. Whether you are doing electronic billing or using a CMS 1500 paper form, each diagnosis code needs to be linked to a CPT code on the claim. Usually they are entered in the same order so it's clear which service was meant to help which problem. Someone who doesn't understand the clinical side of the practice - such as your biller -- might match a diagnosis with a procedure that upon reflection doesn't make sense. "Physicians really need to be specifying what diagnosis they are doing for what procedures. The physician need to be giving the coder all the pertinent information," suggests Rex Stanley, CEO of Unicor Medical, Inc., and a consultant based in Montgomery, Ala. Open lines of communication help. Coders and billers need to feel free to ask physicians follow-up questions based on their documentation. In many practices, staff are afraid to approach physicians. It might also be useful to hold regular educational sessions for all staff about the clinical services the practice provides, especially when a new procedure or service is adopted. Souba also recommends tracking denials by physician or even by procedure so that education can be more targeted. "Identify what it is that is missing, and then it's just a matter of sitting down and really doing the communication," she says. Conquering NCD and LMRPs It's relatively easy to manually catch some odd ICD-9/CPT combos -- the ear infection plus EKG, or even the ear infection plus well child< |
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