Most Commonly Unexpected Denied Procedures

Claim denials are an unpleasant fact of life, and too many of them can dramatically impact your practice's cash flow. Not only do coders have to cope with murky and complicated rules for coding and documentation but at the same time they have the threat of an audit hanging over them, and it's not easy.

Denial management, however, is more than just good coding and documentation. Denial management is a complex process of steps that must be taken to prevent claim denials and appeal those claims that do get denied. Having a process for dealing with denials that maximizes the chances of successful appeals while minimizing waste of time and resources is every practice's dream.

Unfortunately, denials aren't always predictable. It helps to stay up-to-date on the top unexpected denied claims so you can be better prepared when you code and document these services.

Top Unexpected Denied Claims

According to an infographic put together by Physicians Practice, the top unexpectedly denied claims for August 2015 were:

• Outpatient doctor visit, level 3 (99213), of which 7% were denied
• Outpatient doctor visit, level 4 (99214), which also had a 7% denial rate
• Routine blood capture (36415), which had a 14% denial rate
• Subsequent hospital care, level 2 (99232), with a 12% denial rate
• Subsequent hospital care, level 3 (97233), with a 13% denial rate

Reasons given for these denials include:

• Duplicated claims or services
• Claims having been already adjudicated
• Claims lacking information or containing errors
• Claims for non-covered charges
• Claim submission after time limit expiration.

Top Unexpected Denied Claims for Family Medicine

For family medicine practices, the top denied claims for that same time period were a bit different:

• Outpatient doctor visit, level 3 (99213), with a 6% denial rate
• Outpatient doctor visit, level 4 (99214), which had a 7% denial rate
• Immunization administration (90471), coming in with a 12% denial rate
• Subsequent hospital care, level 2 (99232), with a 14% denial rate
• Routine blood capture (36415), which had a 15% denial rate

Likewise, reasons for denied claims were similar to overall trends, but slightly different. The reasons for these top unexpected denied claims for family medicine include:

• Already-adjudicated claims
• Duplicated claims or services
• Claims with errors or missing information
• Procedures not paid for separately
• Non-covered charges

Which Specialties Have the Most Unexpected Denials?

If you have a family medicine or pediatrics practice, you generally face the most unexpectedly denied claims of any specialty, with 11% of claims unexpectedly denied. Following closely, with 10% unexpected denial rates are internal medicine and orthopedic surgery with 10% unexpected denial rates. Radiology rounds out the top 5 with a 9% unexpected denial rate.

How to Protect Your Practice from Unexpected Denials

Generally, if you have a claim that's unexpectedly denied, you can often chalk it up to one of these five reasons:•

•  Duplicate claims
• Claims that omit information
• Expired eligibility
• Non-covered charges
• Time limit expiration

Preventing claim denials requires excellent communication between your coding/billing staff and your clinicians, and it requires verification of patient coverage with each visit. Excellent denial management also requires that you monitor denials over time to detect trends. Is one insurer responsible for most denials? If so, perhaps a phone call could help you learn why so many claims are being denied.

Another way to prevent claim denials is to have outstanding medical billing software that's integrated with your electronic medical records (EMR), and ensuring everyone who uses the software is fully trained. Having a practice management system with built in claim scrubbing and a claims rules engine can save your practice time and money when it comes to effective denial management. Make sure you are fully utilizing your EHR software to improve your practice's communication and processes.