Knock Out Medical Claim Denials With This 1-2-3 Prevention Plan

contact payers about inappropriate medical claim denials

If denial prevention is one of your New Year’s resolutions, we’ve got some ideas to help you achieve your goal. Make 2020 your best year yet by watching the little details that matter for your medical claims, including changes for Appropriate Use Criteria, Medicare Beneficiary Identifiers, and global billing address requirements.

1. Remember That Code Updates Affect Policies

One of the most important actions you can take to help your claims is to ensure your medical codes are up to date. The 2020 ICD-10-CM code set was effective for dates of service on and after Oct. 1, 2019. The 2020 CPT® and HCPCS Level II code sets will be effective for dates of service Jan. 1, 2020, and later, and both of those code sets get additional updates throughout the year. You need to be sure you aren’t submitting deleted codes (which payers will not accept) and that you’re using new and revised codes correctly (to bring in accurate reimbursement and avoid audit issues).

And don’t forget that code changes have ripple effects on payer policies and programs. For instance, Jan. 1, 2020, is the start of the testing period for Medicare’s Appropriate Use Criteria (AUC) program for advanced diagnostic imaging. Information about this program has been available for a while, and Medicare recently had to update Change Request 11268 and MLN Matters article MM11268 to reflect radiology CPT® code additions and deletions that have occurred over the last couple of years.

As one last tip, watch your claims after code updates to be sure there aren’t inappropriate denials. Payers may not update every policy and claim edit in time for implementation (we’re all human, after all), so if you notice that your services are being denied incorrectly, get in contact with the payer quickly so they can make the required adjustments.

2. Make Sure You’re Using MBIs

The transition period to the use of Medicare Beneficiary Identifiers (MBIs) instead of Social Security number-based Health Insurance Claims Numbers (HICNs) ends Dec. 31, 2019. As of Jan. 1, 2020, you must use MBIs on claims even if the date of service is before January 1.

Medicare offers a few exceptions to the MBI requirement. For instance, for appeals and audits of prior services, use of either the MBI or HICN is OK. But your new claims need to have the MBI to avoid rejection.

Medicare contractor Noridian also shares this advice: Be sure you’re providing labs, reading radiologists, and durable medical suppliers with the MBI on referrals and orders when appropriate.

3. Watch for Updates to Non-Coding Requirements

Medical claim forms have a lot of fields, and it often takes a whole team to fill it in correctly. Along with items like patient information and medical codes, you’ve got some interesting extras to worry about.

For instance, effective March 9, 2020, Medicare will add new sections on global billing (professional and technical components) to Medicare Claims Processing Manual, Chapters 1 and 35. In short, the additions state that your claims will have to include the address where the technical component was performed when you bill the global diagnostic service code. The information will go in Item 32 (or the electronic equivalent).

The lesson learned is that team members need to stay current on requirements for the fields they are responsible for to avoid claim issues.

What About You?

What’s your top tip for denial prevention?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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