Most Common Reasons for Medical Claims Denials and their Remedies

Today’s physician and doctor office faces shrinking reimbursements and increased claim scrutiny from third parties. If your practice is like most, it gets most of its revenue from submitting CPT and ICD-10 codes. Third party denial of your claims costs your practice – and all the physicians practicing there – big bucks.Remit Data, an independent ...

Today’s physician and doctor office faces shrinking reimbursements and increased claim scrutiny from third parties. If your practice is like most, it gets most of its revenue from submitting CPT and ICD-10 codes. Third party denial of your claims costs your practice – and all the physicians practicing there – big bucks.

Remit Data, an independent source of healthcare data analytics, regularly compiles a list of the most common denials for medical claims filed in February of 2014.

Top Five Most Common Unexpected Denied Procedures

  1. 99213: Outpatient doctor visit, level 3
  2. 99214: Outpatient doctor visit, level 4
  3. 36415: Routine blood test
  4. 97110: Therapeutic procedures
  5. 99232: Subsequent hospital care visit, level 2

Practitioners are often surprised when a payer denies payment for a 99213 procedure, as many physicians and coders look upon 99213 as the default code for almost every E/M service. It is possible many filers think any higher code would require too much information or that 99214 are beyond the level of service they really rendered.

On the other hand, payers are increasingly rejecting 99214 submissions because practitioners seem to be filing more 99214s than ever before.

Speaking of unexpected denied procedures, who could have predicted denial on payment for 36415? They are, after all, just routine blood tests.

The Top Five Reasons for the Top Five Unexpected Denials

The Claim Adjustment Reason Codes, or CARC, sheds light on why payers denied those claims so frequently. Remit Data also lists the top five CARC codes and reasons for those top five common denied procedures:

  1. 18: Duplicate claim/ service
  2. 97: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
  3. 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided
  4. 96: Non-covered charge(s). At least one Remark Code must be provided
  5. 109: Claim/service not covered by this payer/contractor

Most CARC 18 violations are the result of simple mistakes but this error can cause loss of revenue and major headaches. Medicare reminds providers and suppliers to stop filing duplicate claims, as doing so may delay payments. Medicare also warns that they identify providers and suppliers who file duplicate claims regularly as an abusive biller. Medicare officials may launch an official investigation potentially resulting in fraud charges if they see a pattern of abuse develop.

CARC 19 is the newest addition to the top five lists. In January of 2014, reason codes 29 and 22 took the numbers 4 and 5 spots, respectively.

CARC violations are usually process-related issues that you can solve with relative ease through additional training for everyone who uses codes. Assess your current compliance management systems, and look for ways to improve compliance. Consider implementing pre-submission payer and contractor confirmation. While these resolutions might be time consuming at first, they greatly reduce claim denials and potential trouble with Medicare.

Source: remitdata.com