b'CODING Update ComplianceFight the Denials!By David Kein ANJC Coding & Compliance ConsultantLEGAL NUTRITIONUpdateRecently there has been an uptick in providers who arein date of onset when an office visit and CMT code are billed receiving denials for billing an Evaluation and Managementon the same day.However, in many instances, box 14 is (E/M) code, 9921299213, at the same encounter as a CMTnever updated by providers and the service is subject to the (98940-98943).Despite using the -25 modifier, the denialautomatic denial.Remember, your documentation is not the ANJC News states that, per the NCCI edits and the insurers policies, theonly way to justify services, the claim form is an important ANJC Leadership ANJC News! E/M code was bundled and not payable.Official verbiagetool in this communication with insurance payers.from NCCI edits says that the E/M code .may be reim-bursed if an NCCI-associated modifier is appropriate andNUTRITION There are other areas on the CMS 1500 form that the LEGAL EASE provider can update to proactively let an insurers software used.Despite this language, it appears as though many ofknow that the use of the E/M service is appropriate.For these insurers have instituted an automatic denial withoutexample, if a patient presents with a new condition, then ever reviewing the providers documentation to see if thisthere would be a new diagnosis listed on the claim.Or, if code combination was appropriate.there was a change in the patients condition, the diagnosis While there are times when providers bill for the E/M serviceREHAB Update hierarchy/order would likely change.Additionally, if an ANJC Scholarships evaluation is necessary for a new condition/diagnosis, then and CMT when it is not appropriate, there are, however, many times when these denials are erroneous.Suchpointing the new diagnosis to the E/M code would be automatic denials are very difficult to deal with as it requiresappropriate. the provider to take the time and appeal the claim.WhoThe third step is to make sure you have rock solid docu-has time to appeal?This administrative burden often resultsmentation in case you do need to send in your notes to in providers simply writing the E/M service off and receivingCHIRO Assistlowered reimbursement.appeal and support the service.Simply performing and documenting the evaluation is not sufficient.Any time a LEGAL Q&A re-evaluation is performed, providers must overtly state What can providers do to limit these denials?While you will Executive Directors Update never be able to eliminate these denials, you can reduce thewhy the evaluation is necessary.For example, if a patient number of automatic denials by taking some simple steps atexacerbates their condition, at a minimum, documentation the documentation and claim level. 2020 ANJC AWARDSshould make it very clear that 1) An exacerbation occurred; The first step is to understand when it is appropriate to bill2) How it occurred; 3) Subjective and objective comparisons for an office visit and CMT on the same date of service.Forbetween where they are now and where they were before certain insurers, billing a re-evaluation at regular intervalsthe exacerbation; and 4) How it affected the current treat-(say every 30 days) is never acceptable.While you couldment plan and changes to the plan.Simply stating that an Legislative Update exacerbation occurred is not enough.argue that Medicare and best practice disagree with INSURANCE Update INSURANCE Update such a policy, the fact is, insurers are allowed to make theirFor providers, denials will always occur and are a cost of own reimbursement policies, and therefore you will needdoing business.However, by implementing the above steps, to accept it for those payers or continue to face denials. TECHNIQUE Updateproviders can reduce the number of automated denials and Despite this, there are times when it is appropriate (in almostbe more successful on appeal.Everything you do in practice all circumstances), as follows: tells a story.Documentation, coding, and proper completion 1. New Patient Evaluation of the claim form are all critical forms of communication to the payer and have a significant impact on successful 2. Exacerbations reimbursement. MedicareQ&AMedicare Update New Conditions3.The second step providers must realize is that, in mostOUR HEALTHDavid Klein, CPC, CPMA, CHC, is co-founder of PayDC, a cases, these denials are computer driven.Insurers haveweb-based fully certified EHR system that focuses on compliance put in place edits that first look for code combinationsand reimbursement.He is a certified professional coder and(e.g., 99213 and 98941), and if they are found, the systemcertified professional medical auditor through the American then looks for other markers on the claim to support thatAcademy of Professional Coders (AAPC), and is certified inparticular code combination.For example, if a patienthealthcare compliance through the Health Care Complianceexperiences an exacerbation, there would likely be a newBoard (HCCB).He is the Founder and President of DK Codingdate of onset to identify it.On the CMS 1500 claim form,& Compliance, Inc. a health care consulting firm that focuses on audit defense, education, compliance and reimbursement issues. the date of onset is found in box 14, and in such instances, this should be updated to reflect the exacerbation.Insurers software will often look at box 14 to see if there is a change www.njchiropractors.com I 9'