Denials Part 1

Something all medical billers deal with is denials.  You can do your best to post charges correctly, make sure all the proper modifiers and diagnosis codes are in place so you can send nothing but clean claims, but unfortunately denials are still inevitable.  Although most of you medical billers out there are most likely extremely familiar with different kinds of denials, I think it would still be beneficial for you and for medical billing students to review the basics.  This will be part one of a series of posts about denials and how deal with them. 

I thought I'd start with Medicare denials which can be more complex as Medicare has Claim Adjustment Reason Codes as well as Remittance Advice Remark Codes.

Claim Adjustment Reason Codes - Communicate why a claim or line item was denied.

Remittance Advice Remark Codes - Provide an additional explanation.

The image below shows an example of a Medicare explanation of benefits. I have circled where you can find these denial codes.  Of course the location of these codes on the page may vary depending on the layout you are using in your office.

Some of the more common Claim Adjustment Codes I work with are:

24 - Charges are covered under a capitation agreement/managed care plan. This is one I see a lot ever since Medicare Advantage plans started popping up everywhere.  If you see this code it means that you should not be billing Medicare directly.  The patient has a Medicare HMO plan through a different insurance company.  Check with the patient to find out which insurance it is so you can bill that insurance directly.  Sometimes patients get confused and present the insurance card as their secondary plan.  If this is the case be sure to explain to the patient that it is not secondary, it takes the place of Medicare.

29 - The time limit for filing has expired. The claim was submitted too late and will not be paid unless you submit proof of timely filing from your computer system or clearinghouse.

27 - Expenses incurred after coverage terminated. Coverage is no longer in effect.  Call the patient to get current coverage information, or if you don't have time or cannot get a hold of the patient, send them a bill.

97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This means the service took place during a global period (within a certain number of days after a procedure). Look at the diagnosis code used. Is it the same diagnosis used in the original claim?  If not, a global modifier needs to be added.  A modifier 24 for an office visit or a modifier 79 for any other procedure will tell them this claim has nothing to do with the previous claim.  If so, this should have been considered a no charge post-op visit, unless the doctor can provide you with a different diagnosis also discussed during the visit.

50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer. Medicare can be very picky about what diagnosis codes can and cannot be billed with certain procedure codes.  If you receive a medical necessity denial you need to look at the LCD (Local Coverage Determinations) list to find which diagnosis codes are accepted. Then ask the doctor to choose one of those codes if applicable.  You can find LCD lists on the CMS.gov website or just click here.

140 - Patient/Insured health identification number and name do not match. There is a problem with the way the patient's name is spelled in your computer system.  Check the patient's Medicare card.  Every part of the name has to match including the middle initial.  If one little thing is off, Medicare will automatically deny the claim. Sometimes if I can't figure it out I will play around with the patient's name and date of birth combination on the Endeavor website until I "crack the code" and it shows me the name the way they have it spelled.

31- Patient cannot be identified as our insured. This means the Medicare ID number is entered incorrectly.  If you have verified the number with the patient's Medicare card and double checked it with the patient's social security number (if the patient provided you with one), then chances are the problem lies with the letter at the end of the ID number.  These letters can sometimes change. I will usually go to the Endeavor website and play around with it, changing the letter from an A to a T or a D until eventually when I get it right the website will allow me to view the patient's eligibility information.  If this doesn't work, try calling the patient to ask if they know if the letter in their ID number has changed. Denials can be a pain, but knowing what they mean is half the battle.  Do you have any additional tips or denial codes you think should be included on this list?  Please add a comment!  I always welcome suggestions and feedback.

TC vs 26

Do you know what the difference is between modifier TC and modifier 26?  If not, you're not alone!  There are many doctors and medical billers who don't know the answer to this question, and they are keeping their practice from collecting money that is rightfully theirs because of it.  Today I will explain the difference to you and tell you how to properly use these modifiers.

TC - This stands for "Technical Component" which is used to indicate the technical part of a diagnostic procedure.

26 - This is the professional component which is the interpretation of the procedure.

To help clarify this I will give two examples.

Example 1:
A patient goes to see his dermatologist to have a few moles removed.  Once removed, as a standard of care, the dermatologist sends these specimens to a laboratory to prepare pathology slides.  When the laboratory sends the slides back to the doctor she reads them and makes a diagnosis.  In this case because the laboratory prepared the slides but did not read them, they would bill this as 88305 - TC whereas the dermatologist who read the slides but did not prepare them would bill 88305 - 26.

Example 2:
A patient goes to her primary care physician because she injured her ankle and thinks it might be sprained. The doctor has her go to a radiology imaging office for x-rays.  When the x-ray images are ready they are sent back to the doctor who reads them and contacts the patient to let her know that her ankle is indeed sprained.  In this case the radiology imaging office would bill 73610 - TC and the doctor who read the x-ray would bill 73610 - 26.

Are you starting to see the trend?  The concept might seem confusing to some, but when you look at these examples it's actually pretty straight forward.  There are of course a few other scenarios I have not yet discussed. 

• What if the dermatologist sends the patient's specimens to a laboratory that both prepares the slides and reads them?  Then the doctor would not bill any pathology and the laboratory would bill 88305 by itself.

• What if the laboratory prepares the slides and reads them, but the dermatologist prefers to read the slides as well, just to make sure the laboratory read them correctly?  Because the laboratory already read the slides and billed them, the doctor cannot bill them again. The patient's insurance company will not pay for the reading twice.

• What if the primary care physician has an in-house x-ray technician that can take the x-ray in the office and give it to him to read within minutes?  Then the doctor would bill a 73610 by itself.

As you can see, when the entire diagnostic procedure is done in one place from start to finish there is no need to use the TC or 26 modifiers.  These modifiers are only used to specify which part of the procedure was done when they are done separately.  Reimbursement from insurance will be higher when neither modifier is used because reimbursement will be for both the technical and professional components. 

NOT USING THESE MODIFIERS PROPERLY COULD LEAD TO INSURANCE FRAUD...
If your office only does one component but not the other and you are billing for both by not using a modifier, this is considered insurance fraud!  By billing the CPT code without the appropriate modifier you are telling the insurance that your office did the diagnostic procedure from start to finish.  If this is consistently done and yet the insurance is getting claims from the laboratory or other provider that has done the other half of the procedure, it will definitely raise a red flag and your office is likely to be audited.

...OR MONEY LEFT ON THE TABLE!
I cannot tell you how many times I have gone to a billing seminar where these modifiers were discussed and heard one of the doctors also attending the seminar say, "I have been doing both the technical and professional components, but someone once told me it had to be billed with a modifier 26, so that's what I've been doing for years!"  Don't blindly trust what someone tells you when it comes to how to bill something.  Don't even blindly trust what I tell you. ALWAYS research and double check on trusted billing websites or if your practice belongs to a medical society you can call them up and ask them your billing questions. It's worth the effort to make sure you are collecting every penny your doctor has worked so hard to earn.

Patient Phone Calls - Part 2

In my last post I went over what I consider to be the first rules of good customer service when dealing with a billing related patient phone call.  If you'd like to refresh your memory or you haven't read Patient Phone Calls - Part 1 you can find it here.

 

If you've already listened to the patient, given them the benefit of the doubt and explained all the charges and insurance payments in detail and the patient is still arguing with you - don't worry, there is still hope!

• GIVE THEM FACTS TO EARN THEIR TRUST - Usually if a patient is calling to dispute their bill it's because they think you didn't bill their insurance or you didn't post their payment correctly or perhaps didn't post it in their account at all.  If this is the case I will usually say something like, "We did bill Blue Shield on the 24th and they have already processed the claim but applied a portion to your deductible," or "I do see here that we received a payment of $138 from you on February 11th, but that payment was applied toward your previous visit in January.  The amount you currently owe is from your most recent visit with Dr. Smith on March 3rd." By telling them what you did do or what payment of theirs you do see, you are putting them at ease and helping them draw the conclusion that you are competent and everything has been posted to their account correctly.  Once they have that trust in you they will most likely take you at your word and pay the bill.

• KEEP YOUR TONE CALM BUT FIRM - I have heard many a co-worker make a patient call go downhill very quickly by stooping to the patient's level.  If you fight fire with fire, there is absolutely no way the patient's issue will get resolved, and you can bet the conversation will not end on good terms.  Dealing with an argumentative patient is not the same as dealing with a difficult family member or friend.  You have to swallow your pride, be professional and do what is in the best interest of the practice.  However, you cannot let the patient get their way just because they are yelling.  What I do is wait for them to finish and then calmly say, "I'm very sorry you feel that way sir, and I do understand why you are frustrated.  But your insurance is saying this is balance is your responsibility."

• DO NOT TOLERATE DISRESPECT - It is one thing to swallow your pride and continue to be friendly when the person on the other end of the line is not.  But if at any point the patient starts cussing at you, calling you names or threatening you, this is not to be tolerated.  If the patient you are speaking to disrespects you in any way you need to firmly say, "Ma'am, please do not talk to me that way.  I am trying to work with you, but I need you to please stop disrespecting me!"  If the patient does not stop, simply say, "I am going to hang up now. Please do not call back until you are ready to speak with me in a civil manner." 

There you have it - my approach to handling angry patient phone calls successfully.  By no means can I say these tactics work 100% of the time, but they do work most of the time.

What is your approach? Do you have any tips or tricks that help you resolve patient disputes?  I would love to hear them!

Patient Phone Calls - Part 1

I can't think of anyone who enjoys taking billing related patient phone calls.  Most patients are friendly, but some can be demanding, argumentative and at times very rude.  However, communication with patients is extremely important.  A patient's conversation with the billing department can either increase their loyalty to the practice or make them decide never to return.  Their satisfaction with a billing related phone call can carry almost as much weight as their experience with the medical staff during their visit. 

This might be hard for some of you to believe, but think of it this way.  Suppose you went to a spa for a massage and your experience was so wonderful you had never felt so relaxed and refreshed.  You decide you will definitely be coming back again.  But then when it's time to pay for your massage you are charged more than you initially thought you would owe.  When you ask why, the person behind the desk gives you a vague answer and doesn't bother to explain it to you.  In fact, they get impatient and threaten you when you tell them you won't pay more than what you thought you would owe.  At this point it doesn't matter how much you loved your massage.  You definitely will not be coming back again!

Now I'm not saying a doctor's office would do this, however some patients will call you with the belief that they don't owe as much as you billed them or they shouldn't owe a balance at all.  I've even had a call or two from patients saying "I don't owe you money, you owe me money!"  How do you deal with a patient who is yelling at you because they think they're right and you're wrong?  Here is my approach:

• LISTEN - Give the patient a chance to say everything they feel the need to say. Do not interrupt unless you feel they have gone on too long and are now starting to repeat themselves.

• GIVE THEM THE BENEFIT OF THE DOUBT - Just because your computer system is showing you something different from what the patient is saying doesn't mean the patient isn't correct.  Always investigate.  Leave no stone unturned until you are completely sure.  If this means you have to tell the patient you will look into the matter and give them a call back then by all means do so.  Even if it turns out you were right all along the patient will appreciate that you took the time to double check.

• TAKE TIME TO EXPLAIN THE CHARGES - Statements can sometimes be confusing for patients and they just need a verbal explanation. Break it down for them by date of service. Tell them what each charge was for, how much the insurance paid, how much was written off.  Yes, it can take a lot of time to do this, but if it helps the patient understand why they owe the balance so that they will finally pay the bill then it's worth it.

In Part 2 of my Patient Phone Calls segment I will discuss what you can say to a patient that will immediately put them at ease, what kind of tone you should take and what is the one thing you should not tolerate when dealing with an angry patient.

GETTING TO KNOW YOU

Hello to all my soon to be readers out there!  I am so glad you stopped by to have a look at my new blog.  This blog will be about medical billing, but I can promise you it will in no way be boring. What I love about the medical billing field is there is always something new to learn or some big change coming up.

Before I start sharing knowledge and stories with you, I'd like to tell you all a bit about my background.  I starting working part time at a family practice when I was in college at age 18.  My job consisted of posting charges and over-the-counter payments and pulling charts.  When I finished college (I got a bachelors degree in business administration with a concentration in accounting), they hired me full-time and thus began my official training in medical billing. 

Since then I have done billing for a variety of specialty practices such as:

• Oncology
• Radiology,
• Out-patient Surgery
• Dermatology  

I've worked in small business office teams of 3 or 4, large teams of 15 to 20. I've also worked independently - just me myself and I.  I must say I like it the best because I get to do things my way and according to my time table. I do however believe working as a team can be beneficial if it's done correctly. 

What I like most about billing is that sometimes I get to feel like I'm a detective.  Whether I'm poring over a report to find out why I can't balance or trying to enter the perfect combination of patient data into an picky insurance website to get the specific information I need, there's always a mystery to solve!

 



And now I'd like to hear about you and your medical billing experience. Also, if you have any questions or blog topics in mind for me, please feel free to share! I want my readers to get as much out of this blog as possible and I am open to suggestions.  It's going to be a fun time!