Denial Management - Inclusive & Global

Important Coding denial which should be understand thoroughly to fix it with Lean methods

1. Inclusive denial Denial Series

2. INCLUSIVE Definition Bundling or inclusive is a payment method that combines minor medical services or surgeries with principal procedures when performed together or within a specific period of time. Examples: 71010 (Single View) inclusive with 71020. (Two view)

3. MUTUALLY EXCLUSIVE Mutually Exclusive: Mutually Exclusive Procedures are procedures that cannot be reasonably done in the same session Ex: CPT 81002 when billed with 81000 will be denied 00 . CPT 81000 Urinalysis by dip stick or tablet reagent ; Non automated with microscopy CPT 81002 Urinalysis by dip stick or tablet reagent ; Non automated without microscopy

4. Denial Verifications CCI Edits – CMS/ BCBS McKesson's Edits – Aetna, Cigna, HIP Commercial Web sites Code correct Encoder Pro.

5. Comprehensive & Component Codes The component code will not be paid when it is rendered by the same provider on the same date of service because it is considered to be part of the comprehensive code

6. McKesson's EDITS

7. McKesson's EDITS

8. McKesson's EDITS

9. McKesson's EDITS

10. NATIONAL CORRECT CODING INITIATIVE (NCCI) Medicare established the CCI in Jan 1, 1996. CCI sets standards for billing with CPT & HCPCS codes. The CCI identifies mutually exclusive codes or those that should not be billed together. CCI was introduced to: Establish standards of medical billing. Identify codes that may be a potential for fraud & abuse. Identify codes that are components of another code & should not be unbundled & billed on the same encounter by the same physician

11. REASONS FOR THE DENIAL No modifier used when billing the claim. Incorrect modifier used. Down coding by the insurance. When a higher complex CPT is billed along with the lower complex CPT for the same diagnosis.

12. MODIFIERS Modifiers are codes that are used to “enhance or alter the description of a service or supply” under certain circumstances A modifier is a two-digit code that further describes the service performed Modifiers may be used under the following circumstances :- A service or procedure has both a professional and technical component. A service or procedure was performed by more than one physician and/or in more than one location. A service or procedure has been increased or reduced. Only part of a service was performed. A bilateral procedure was performed. A service or procedure was provided more than once.

13. LIST OF MODIFIERS Modifiers Description 24 Unrelated E & M service 25 Significant & separate E & M 26 Professional Component 50 Bilateral 51 Multiple surgery 58 Staged or Related Procedure 59 Distinct procedural service 76 Repeat procedure by same physician 77 Repeat procedure by different physician 80 Assistant Physician

14. Precall Analysis Check if any related CPT is billed on the same day by provider of same specialty Check the RVU value in Software. If E & M codes are denied check the Global period for the Surgery codes. Check in CCI/McKesson Edits whether any modifier is applicable to the denied CPT Check if the denied CPT is billed with appropriate modifier, included in the other CPT

15. CLAIM DENIED BY MEDICARE AS BUNDLED

16. CLAIM DENIED BY MEDICARE AS BUNDLED Filter by DOS

17. Encoder Pro

18. Encoder Pro

19. Encoder Pro

20. Encoder Pro

21. CCI EDITS 0- No Modifier allowed 1- Modifier is allowed 9- Denial is incorrect

22. Denial Resolutions Check the flow chart Status & action Code IPP – TAP- Telephonic Appeal PWO - Potential Write off, MRR - Medical record request APL - Appeal

23. Global Periods

24. Global Package Pre-op + Surgery+ Post-op

25. Global Period The pre-op and post-op care the patient receives by the physician after a procedure

26. Global Period Are determined by the type of procedure The time frame is different by payer Do not apply to all procedures

27. Why Global Periods?????? It would save on processing separate bills You would be reimbursed for the entire service in one payment

28. Thank You