November 2012

How to Benefit From Medicare Denials — No Kidding, It Could Happen
By Terry Kelly
Radiology Today
Vol. 13 No. 11 P. 12

You may be surprised to learn that your Medicare radiology denials can actually benefit your hospital or practice. These denials actually hold a wealth of information that can assist you in appropriately issuing advance beneficiary notices (ABNs), properly billing claims, and educating ordering physicians on medical necessity while keeping patients from having unnecessary testing and assuring proper reimbursement for services.

In many billing offices, denials are simply written off while managers lament Medicare reimbursement cuts. Though it will take time to review denials and track and trend issues, doing so will help patterns emerge, allowing you to implement policies and procedures to address the denials and keep appropriate reimbursement within your practice.

Review Claims
Larger radiology offices, outside billing services, and outpatient hospital billing systems usually have installed claim scrubber software to review claims for medical necessity edits prior to billing. In essence, by using a claim scrubber, you have the opportunity to address medical necessity issues prior to billing so they don’t end up a denial casualty 30 days down the road. Some providers also may have up-front software to generate ABNs to Medicare beneficiaries prior to providing a service.

Both types of these software products address the medical necessity criteria guidelines that Medicare has in place, basically doing the checking for you and your staff. But you don’t have to buy software to understand Medicare’s medical necessity criteria. You just have to provide some education for your team and have criteria in place to make sure everyone is on board with understanding what medical necessity is and how to verify it—and more importantly, why it’s essential to check for it.

Track and Trend Issues
A simple way to track your Medicare radiology denials is to set up an Excel worksheet. Log in the denials from the Medicare vouchers, making sure to track the CPT code for the radiology procedure and the ICD-9 diagnosis code(s) used in the billing as well as the ordering physician. After a few weeks or months, depending on the size of your practice, the common denials will rise to the top of your tracking sheet, and you also may see a pattern related to one particular ordering physician or practice. In that case, education may be your simple answer.

You also may want to track the dictating radiologist, as you may have an internal challenge in a particular documentation pattern that may be causing your denials. In an outpatient hospital setting, findings on a radiology report are not always coded by the health information management department. If the only diagnosis going out on your claims is from the ordering physician’s order or script, you may be able to alleviate some denials by simply coding findings prior to claim submission.

Taking a few weeks’ worth of denials and doing some detective work by reviewing the original order or script, the bill itself, and the test documentation can help you determine whether you are being denied simply because you are not taking the time to make sure everything is properly coded prior to billing. If the ordering physician is not giving an ICD-9 code but instead writing out the diagnosis, you must self-audit to determine whether all the diagnoses written are being converted into codes and whether that is being done properly.

For example, is the ordering physician’s handwriting illegible? Is your team guessing at a diagnosis after passing the script around to two or three team members to decipher the diagnosis written on the order? Is it a “rule-out” diagnosis, which really is not a diagnosis at all and shouldn’t be coded? Look instead for a sign or symptom. As simple as this may seem, denials don’t necessarily have to be complicated; they may just be due to poor communication or documentation issues.

If you have a software package that produces a denial report, is anyone looking at the detail of those claims or are you just reporting on the dollars lost due to Medicare denials? Self-auditing your practice and/or your billing company is a necessity rather than a luxury.

If you are an outpatient hospital radiology department and use a private radiology group for readings, become best friends with the office billing manager at the radiologist’s office. Chances are you are both seeing the same denials. Sit down together and review them and come up with a strategy to address the challenges together.

Check Current Coding Criteria
Once you have a list of the CPT codes being denied, check the Medicare medical necessity policy for the service. Depending on the Centers for Medicare & Medicaid Services (CMS) jurisdiction in which you are located, this will point you to your Medicare administrative contractor (MAC). Accessing medical necessity policies online is the best way to ensure you are reviewing the most current local coverage determination (LCD) for medical necessity criteria.

If it is a national coverage determination (NCD), checking the CMS NCD website is easy once you have the CPT code in question. When you review the Medicare policy, be sure to check not only the acceptable diagnosis codes for the procedure in question but also the section titled “Indications and Limitations of Coverage.” This section of the policy can provide valuable information on any appeals you may have to submit to Medicare.

While a particular ICD-9 code may not be present in the policy, there may be an indication in this section that would support the test, provided that you have the information documented and can provide legible medical records to support the indication. You also may need to reach out to the ordering physician for additional documentation to support your appeal. This section of the policy also will list frequency limitations for the test and how those limitations can be overridden in certain clinical circumstances.

The other section of an LCD or NCD that you want to review is at the bottom of the policy under “Other Information.” In this section, you can see documentation requirements, which again will help you submit more pertinent appeals, and a section called, “Revision History,” in which you will see updates to this particular policy. If there are procedure or diagnosis code revisions, deletions, or additions, they will be listed here.

Pay attention to the effective date of the revision. While in the body of the policy you may see the diagnosis code you submitted listed as meeting medical necessity, the date of service may be prior to or after the revision’s effective date.

You also need to check the “Article” section of the MAC’s policy section. While there may not be an official LCD on your MAC’s Web page, there may be an interpretive article on a CMS NCD, and sometimes you will have to review both the LCD and the associated article for little nuances not immediately visible in the policy alone.

Proper Education
Once you have determined your higher-risk denials, you can use this information to implement an appropriate ABN procedure in your practice. Even if your office is not “high tech,” find the LCD or NCD on the MAC or CMS website and mark it as a favorite. (Routinely check the policy for updates so you have the most current version as a favorite. If you are printing off the policy, make it someone’s responsibility to check for revisions monthly and update accordingly.)

If a patient presents with an order for a test in your high-risk denial pool, always check the medical necessity criteria prior to providing the service. When appropriate, issue the ABN to the patient explaining that he or she will be financially responsible for the test. Provide a private area for the patient to call the ordering physician or assist the patient in discussing Medicare’s medical necessity criteria with the ordering physician.

Chances are the ordering physician will have documentation in office notes that, when provided on a correct order, will give you a diagnosis code to meet medical necessity requirements. The ABN will no longer be needed, and you will be appropriately reimbursed for the services rendered.

If the ordering physician cannot supply additional information to support medical necessity for the test, then it may be appropriate for the patient to ask the physician whether the test is appropriate and medically necessary. We all want to image wisely, so having these conversations with the ordering physicians, while uncomfortable, may keep your patients from unnecessary radiation. Educating ordering physician offices is time consuming and can sometimes be met with the “not my problem” attitude, but choosing to ignore needed education will only ensure additional denials for you, not for the ordering physician.

Reviewing denials, tracking and trending issues, going back to root cause, and providing education to ordering physicians and Medicare beneficiaries will all help to keep your claims from being a medical necessity casualty time after time.

— Terry Kelly is the radiology business manager for Ocean Medical Center in Brick, New Jersey, part of the Meridian Health Family. A frequent educational speaker for Meridian Health’s physician office manager programs, she also has presented programs on denial management.