Medical Coding & Billing: Tips to Improve Your Appeals Process

A particular practice after ensuring it has not made any medical coding and billing entry error automatically appeals payer denials using a standard letter. However this wasn't working in getting them their payments. The question is: How can it boost its appeals process?

Well, before starting the appeal process, one needs to check the payer's policies first. Say for instance if the payer has a policy that bundles dipstick urinalysis (81002) into any evaluation & management services carried out on the same day and will not be reimbursed separately, one should not appeal these. Writing appeals takes up a lot of time. As such you wouldn't want to waste time on appeals you cannot win since already there is a specific policy in place.

What you should do:

Next time, you should follow the payer's appeal procedure just as it is. Many a time, the address to submit appeals is different from the claims address and some payers require you to send a special form with the appeal.

Being specific is the key:

In place of sending a generic appeal letter for every denial, you can customize your letter with the proper key words for each situation. Say for instance you submitted a claim for an evaluation and management service and injection on the same date. You added modifier 25 to the evaluation & management service code, however the payer still denied it.

Here's what you can do: Instead of sending a letter saying 'the claim was submitted correctly', send a letter that addresses the specific claim and the specific reason why modifier 25 was spot on. What's more, you should quote industry guidelines (say for instance CPT and/or CMS guidelines) and if likely the insurance company's own guidelines.

Appeal letter tips: Writing an appeals letter can take up a lot of your time. However you can save time by figuring out your most frequent denials and creating fill-up-the-gap appeal letters for each of these situations.

Say for instance you may find that you get many denials for bundling issues even when you use modifier 59 correctly. Most probably the letters you put together will begin and end basically the same. By creating a base template you can focus on filling in the details for each claim instead of writing each one from scrape.