Two of the most common modifiers are 25 and When modifiers are used incorrectly, the services to which these modifiers are appended will be denied. Practices can help prevent these denials by making sure coding and billing staff are educated on the appropriate and inappropriate uses of common modifiers. Many practice management systems can also assist in reducing these denials by enabling the practice to establish error alerts when codes have been used incorrectly.
For example, a practice may create an alert that will warn the coder when modifier 25 has been incorrectly added to a code between and , which represent procedures. Data discrepancies. Inconsistency in data submitted on a claim will result in denial of services. Examples include a diagnosis specific to female conditions used on a male patient, a flu vaccine billed with a diagnosis describing a pneumococcal vaccine, and a procedure code for neonates billed for an adult patient.
Frequently, these denials are the result of transposed numbers or inadvertent data entry errors. To prevent them, practice management systems may have the ability to issue alerts to warn data entry staff when a discrepancy has occurred. For example, a practice may define diagnosis codes related to pregnancy and childbirth as female-only codes. If a diagnosis related to pregnancy or childbirth is entered for a male patient, the coder will see an error alert and the claim will not be submitted until the issue is corrected.
A practice's efforts to reduce denials should begin with an understanding of its greatest source of denials. To identify the source, run reports of denials for a period of time, such as a week or a month. The reports should display denial reasons, procedure codes reported, modifiers, diagnosis codes, and payers. You can then sort the report by each of these fields to determine whether your practice can achieve the greatest improvement by focusing on a particular payer, a particular service, or a particular coding issue.
The next steps are to provide staff members with education perhaps start by having them read this article , implement practice management alerts, and put other corrective measures into place. To make the process of filing corrected claims more efficient, consider using a standardized claim correction form.
Download FPM 's claim correction form. Next, monitor your practice's progress periodically and provide feedback to those involved in correcting the denials. You may consider setting incremental goals for your most significant denials and then celebrating improved performance. In the world of decreasing reimbursement rates, this potential for cost savings and improved cash flow can dramatically improve a practice's financial health in a relatively short time.
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Was this page helpful? Thanks for your feedback! Sign Up. One of the sources of administrative healthcare costs stems from the complex medical claims process. When the contents of a medical claim spur a debate in our healthcare system, it takes a lot of time, money and resources to resolve the problem properly. When it comes to resolving medical claims, there are a variety of stages that can impact the cost of healthcare administration and the overall outcome for the provider, payer and patient.
Denied claims are medical claims that have been received and processed by the payer, but have been marked as unpayable. Some of the issues for denials may include missing information, non-covered services per plan or even not medically necessary services. It must be determined why the claim was initially denied. Most of the time, denied claims can be corrected, appealed and sent back to the payer for processing.
However, this process can be time-consuming, expensive and requires a lot of resources to get to the core of the issue.
If a denied claim is resubmitted without an appeal or reconsideration request and not as a corrected claim, it will most likely be considered a duplicate claim and denied again. Time is also a factor when resubmitting denied claims. Each payer allows only a certain amount of time to send in a corrected claim.
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