Reducing E/M Services Claim Denials

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Reducing E/M Services Claim Denials

• E/M Services Denial Reasons
• As per the Centers for Medicare Medicaid
  Services (CMS) data, approximately 15 percent of
  evaluation and management (E/M) services are
  improperly paid and accounted for almost 9.3
  percent of the overall Medicare fee-for-service
  improper payment. Some of the common denial
  reasons are similar services from multiple
  providers in the same group Correct Coding
  Initiative (CCI) inaccurate bundling duplicate
  claim submission and inaccurate billing for
  global surgery. So, lets understand these
  denials their resolutions to reduce evaluation
  and management (E/M) services denials.
• Common E/M Services Denials
• Similar Services
• One of the common claim denial reasons is
  similar services from multiple providers in the
  same group. You will receive this denial because
  the payment was already made for the same/similar
  service(s) within the set time frame. When you
  receive this denial, first verify that the denial
  is not based on previous payment information.

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Reducing E/M Services Claim Denials

• To avoid this denial, be aware of the following
  billing tips
• Physicians in the same group practice who are in
  the same specialty must bill and be paid as
  though they were a single physician.
• When more than one E/M service is provided to the
  same patient on the same date by more than one
  physician in the same specialty in the same
  group, only one E/M service may be reported
  unless the E/M services are for unrelated
  problems.
• Physicians in the same group practice but who are
  in different specialties or subspecialties may
  bill and be paid without regard to their
  membership in the same.
• If the claim needs to appeal, signed medical
  documentation should be provided to justify the
  services that were provided on that date of
  service. On appeal, the identification of the
  providers subspecialty, when more than one
  provider from the same group is billing for E/M
  services to the same patient on the same date,
  can be helpful in explaining why multiple
  providers were needed.
• 2. Inaccurate CCI Bundling

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Reducing E/M Services Claim Denials
Practices often make mistakes in choosing correct
codes resulting in claim denials. Correct Coding
Initiative (CCI) is taken by the Centers for
Medicare and Medicaid Services (CMS) to develop,
promote, and encourage correct coding practices
in order to prevent payments that could be given
in error. The purpose of the CCI edits is to
prevent improper payment when incorrect code
combinations are reported. You can check the CCI
edits prior to claim submission on the CMS
website. These CCI edits are updated quarterly.
Conduct internal audits of documentation versus
code selections, especially for E/M services. 3.
Duplicate Claim Submission When insurance
carriers found you submitted more than one claim
for a single service, you will receive remittance
advice as, Duplicate Service(s) The same service
submitted for the same patient, same date of
service by the same doctor will be denied as a
duplicate. To avoid this denial, the claim status
should be checked to verify that the claim
duplication is not based on previous payment
information. In most cases, multiple E/M services
that are performed on a single date by the same
provider must be combined and submitted as a
single service. 4. Global Surgery Denials
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Reducing E/M Services Claim Denials
CMS determines the global days of surgery. As
part of the Medicare Physician Fee Schedule
database (MPFSDB), the codes all include their
global information.  Please check the website for
any surgical code that might cause your claim to
deny. The global day field on the physician fee
schedule will have the information on global day
coverage information. For example, if the global
days are 90 then major surgery with a 1-day
pre-operative period and the 90-day postoperative
period is included in the fee schedule
amount. Please note that evaluation and
management (E/M) services can be payable
according to certain guidelines within a global
period. Verification of the post-operative global
days for the services provided and the
appropriate diagnosis information will help make
sure that any action taken to correct the claim
will be approved. To prevent your E/M claims
from being denied, CMS recommends a number of
strategies. First, in addition to the individual
requirements for billing a selected E/M code, you
should also consider whether the service is
reasonable and necessary. For example, while it
is possible to provide and document a level 5
office visit for a patient with a common cold and
no comorbidities, it is unlikely that anyone
would consider that level of service reasonable
and necessary under those circumstances.
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Reducing E/M Services Claim Denials
Another strategy is to consider various factors
while choosing the correct codes for E/M
services. Key variables when selecting codes for
E/M services include patient type (new or
established) setting/place of service and the
level of service provided based on the extent of
the history, the extent of the examination, and
the complexity of the medical decision making
(i.e., the number and type of the key components
performed). Finally, the fact sheet emphasizes
the need to obtain the necessary
physician/non-physician provider
signatures. Medical Billers and Coders (MBC) is
a leading revenue cycle company providing
complete medical billing services. We can assist
you in reducing E/M services claim denials to
receive accurate insurance reimbursements for
delivered services. To know more about our
medical billing and coding services, email us
at info_at_medicalbillersandcoders.com or call
us 888-357-3226.