Orthopedics And Sports Medicine Network Turns Denied Claims Into Approvals

Referred by an existing client, Infinx initiated an account receivable (A/R) project for a four-location advanced orthopedics and sports medicine group in the greater Houston, Texas area. With a full complement of sports and rehabilitative services, including orthopedic surgery, physical therapy, sports medicine, interventional spine treatment, and chiropractic medicine, the practice was experiencing inflated accounts receivable and a high number of denied claims.

Denied Claims Sitting In A/R Stifle Revenue

The client requested that we complete an overhaul of accounts receivable, including claims from previous years. We identified a significant number of denied claims stemming from a lack of documented medical necessity as determined by various insurance payers through the practice’s coding of services. These denied claims sat unresolved in their aged A/R until the start of this project.

While this severely impacted the practice’s revenue and bottom-line, it also exposed them to potential fines and legal ramifications through miscoding or inaccurate coding and billing practices.

Denied claims plague all medical specialties. Recent transparency data released by the Centers for Medicare and Medicaid Services across HealthCare.gov reveal that nearly 17% or nearly one in six of in-network claims are denied. When 41% of appealed claims are eventually approved, that just .02 percent of consumers and providers make the effort to appeal claims is a tragedy.

Coding And Documentation Gaps Prompt Denials

While our AR team worked to optimize the practice’s outstanding receivables, questionably coded claims were isolated and forwarded to our Nurse Code Reviewer for specialized oversight. It was quickly determined that the practice had some significant documentation process deficiencies. They also lacked a coding team that was willing to challenge the providers regarding denials and documented findings.

To prevent denials caused by under-coded or under-documented claims, the provider must demonstrate the correct status (i.e., admission versus observation) in the right setting/location (i.e., hospital versus practice) on the patient’s claim. They must also include the CPT and ICD-10 codes that support medical necessity. These codes must correspond with the provider’s documentation.

The most common reasons for medical necessity denials include:

• Invalid diagnosis codes
• Incorrect CPT codes
• Incorrect level of service
• Payer policy criteria not me
• Incomplete medical documentation supporting clai

Certified Nurse Code Reviewer Achieves Coding Accuracy

Using Medical Necessity Criteria (MNC) and evidence-based clinical guidelines, our Nurse Code Reviewer was able to compare the rejected claims in question with the medical documentation available through the EHR/EMR and the appropriate insurance payers’ policies. The reviewer determined where the inconsistencies resided.

Example #1

• Patient A, utilizing a national insurance payer, was seen for bone stimulation, non-invasive, spinal (E0748)
• Claim was filed and denied with diagnosis code for Fracture of T12, severe spinal stenosis, severe kyphosis
• Payer policy review determined that for the patient to meet MNC, they must have met one of the following: failed fusion where nine months has elapsed since the last surgery, following multilevel fusion surgery (3 or more vertebrae) or following spinal fusion surgery where there is a history of previously failed spinal surgery
• It was determined by our Nurse Code Reviewer (through review of the hospital record, as well as the practice chart), that the patient had previous spinal surgery in 2014 and did not improve, which led to this second surgery in 2019. This constituted qualification for failed fusion surgery that was not billed on the original claim
• Our specialists corrected the claim, including the diagnosis code for failed fusion surgery, and resubmitted the claim for processing. The claim was processed and paid.

Example #2

• Patient B, utilizing a national insurance payer, was seen for an MRI or the shoulder
• Claim was filed and denied with diagnosis code for an MRI of the right shoulder
• After review of the medical documentation and the rejected claim, it was determined that the wrong diagnosis code was used and resulted in an insufficient MNC determination by the payer
• The claim was corrected and resubmitted on behalf of the practice and was processed and paid

Claims Resubmitted With Accurate Coding

Review, Revision, and Resubmission of Mis-coded Claims — As we processed the A/R, claims with questionable coding issues were forwarded to the Nurse Code Reviewer for resolution. Once changes were determined, claims were resubmitted for final adjudication.

Training for Providers and Coding Team — The practice determined that they would resume A/R management’s responsibilities and revenue stream. To do so effectively, we provided a comprehensive training program for the providers and the coding team that included orthopedic-specific procedures and timelines for documentation, and coding specifics designed to maintain their AR and continue to improve their revenue.

If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.