Three Steps To Coding Appeal Success: Improve Coding Appeals Now To Put Pressure On Payers To Divulge Coding Edits

Payer coding edits confuse and confound the most experienced coders. However, challenging a payer’s coding determination often results in more confusion, more frustration and a single line of computer-generated insurer-speak such as “paid according to the plan or policy benefits.”

Such explanations of benefits are little help and should be viewed as particularly unacceptable to those practices concerned about the upcoming ICD-10 implementation and the likelihood that payer coding edits may greatly impact reimbursement in 2014.

Now is the optimum time to increase your demands that payers provide clear, consistently-applied coding edits so that both sides, payer and provider, understand how benefits are calculated and what coding variables directly affect the reimbursement level. If your payers seem unwilling to explain coding edits upfront, the appeal process provides a way to make a case-specific demand for coding edit disclosure. There are specific legal protections applicable to most payer appeal processes which require the disclosure of detailed information related to coding decisions and your payers adherence to these appeal protections will be especially critical during the ICD-10 implementation process.

As follows are the Appeal Solutions Three Steps to Coding Appeal Success. Implement this process now and your ICD-10 readiness will benefit from both a better understanding of currently applied edits and a well-established procedure for demanding disclosure and detailed explanations of newly launched coding edits and how they affect reimbursement.

  1. Step One: Establish a review process for “outlier payments.” Outlier payments are those payments which are significantly lower than the anticipated reimbursement for that type of claim. The review process should involve assessment of these outliers for the potential inaccurate application by the payer of downcoding, modifier reduction or bunding edits.
  2. Step Two: Appeal outlier payments. The type of appeal letter depends on the reason for the suspected downcoding or modifier/bundling reduction, such as medical necessity or the ubiquitous “internal coding guideline.” If the coding decision appears to be driven by medical necessity considerations, you may want to outline the clinical justification for the coding utilized by your organization. However, many payer coding decisions do not involve medical necessity and can be appealed by demanding a manual review by a certified coder. A certified coder will likely be in the best position to explain how the payer coding edits affect reimbursement and would possibly provide input regarding treatment variables which might justify overriding a coding edit to allow additional benefits.
  3. Step Three: Persist until payer complies with good information. Payers do not readily provide detailed information about coding edits and many coding appeals will require a Level II or higher appeal. High-level appeal reviewers are likely aware of disclosure laws which may require detailed explanations of how coding edits apply to specific claim scenarios. Therefore, make sure that a Level II appeal draws attention to any specific disclosure request which was not responded to in previous efforts. Consider language such as the following if the Level I appeal response failed to provide specifically requested information:

    It is unclear if this claim was reviewed manually by a credentialed reviewer as requested in our initial appeal. Further, we requested release of your written internal coding guidelines which are applicable to this coding decision. Please be advised, state and federal disclosure laws as well as contract terms may be applicable and require the release of detailed information to substantiate an adverse benefit determination. Therefore, we request a detailed explanation regarding the basis on the decision and release of the credentials of the coding professional who reviewed both the initial and current appeal. It is our position that “paid according to policy/plan guidelines” is insufficient explanation of the internal coding guideline.

If you succeed with the Appeal Solutions Three Steps To Coding Appeal Success, let other organizations know all about it. Coding appeals can result in better understanding of coding decisions and better reimbursement on outlier payments. Payers actively monitor what types of claims are appealed and how much time and resources are dedicated to processing appeals. Therefore, more coding appeals can eventually drive better payers to improve upfront disclosure of changing payment policies to avert a spike in coding appeals.

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