Claim DenialsTo make sure that your medical practice avoids denied claims from insurers, it is important to know which claim codes are the most often denied and why these denials occur.
According to ReMatrix, for the period of March 1 through March 31, 2014, the top most common unexpected medical practice denials fell under the following codes:

Five Most Unexpected Denial Reasons All Practices In US March, 2014
Code Description
CPT Code 99213 Level 3 Outpatient Doctor Visit
CPT Code 99214 Level 4 Outpatient Doctor Visit
CPT Code 97110 Therapeutic procedure, 1 or more areas, 15 minutes each
CPT Code 36415 Routine blood capture
CPT Code 97140 Manual therapy techniques (e.g. Manipulation, mobilization, minimal traction, minimal lymphatic drainage, 1 or more areas, 15 minutes each

 
Data for the same period, but only for Internal Medicine Specialists had three of the top five national reasons for denial. In order they are:

Five Most Unexpected Denial Reasons Internal Medicine In US March, 2014
Code Description
CPT Code 99214 Level 4 Outpatient Doctor Visit
CPT Code 99213 Level 3 Outpatient Doctor Visit
CPT Code 99232 Subsequent hospital care
CPT Code 36415 Routine blood capture
CPT Code 85025 Routine blood work

 
Comparing all practice denials to internal medicine denials we see the following:
 
 

Comparison of Unexpected Denial Reasons All Practices vs Internal Medicine, March 2014
Rank All Practices Internal Medicine
1 18 – Duplicate Claim 18 – Duplicate Claim
2 97 – Bundled Service 97 – Bundled Service
3 16 – Lack Of Documentation 16 – Lack Of Documentation
4 96 – Non-Covered Benefit 109 – Service Not Covered By Carrier
5 29 – Expired Time Limit 96- Non-Covered Benefit

 
For both groups, it seems that the different practice types have much in common as to type of claims denied and the reason for their denial.
The top two claims denied are evaluation and management codes. For all groups the denial is for a level 3 office visit and for internists it is for a level 4 office visit. Regardless of the visit level denied, the overwhelming reason for these denials is denial reason 3 16 – lack of documentation.
With an electronic health record, templates filled out by the physician as he or she renders services help to make sure there is enough documentation to support the visit level chosen by the provider.
Non-covered benefits are another area that brings denials. Proper contract administration and loading into the billing software prevents billing the insurance carrier for non-covered services. While Medicare requires an ABN, other insurances do not. Since almost every provider has every patient sign a financial responsibility form, there is no reason your billing system should fail to bill the patient for non-covered services. Waiting for a denial before billing the patient is a bad idea as you delay your reimbursement and subject your claims to needless scrutiny.
If your medical practice also operates a full or partial clinical laboratory, consider reviewing whether or not to continue the operation of your lab. Lab work is a breeding ground for denials and the reimbursement, when approved, is light.
On a regular operating basis, running monthly denial reports is a great way to understand how your medical practice can collect more income and avoid doing medical procedures for which you are not paid.
Overview of PracticeSuite Medical Billing Software

Last Updated on May 7, 2014