Frequent Denials in Medical Billing

1. Duplicate claim/service.
2. The diagnosis is inconsistent with the patient's age
3. The diagnosis is inconsistent with the patient's gender.
4. The procedure code/bill type is inconsistent with the place of service
5. Payment adjusted because this care may be covered by another payer per coordination
of benefits
6. Expenses incurred prior to coverage.
7. Expenses incurred after coverage terminated.
8. The time limit for filing has expired.
9. Charges are covered under a capitation agreement/managed care plan.
10. Claim denied as patient cannot be identified as our insured
11. Benefit maximum has been reached
12. These are non-covered services because this is not deemed a "medical necessity" by
the payer.
13. These are non-covered services because this is a routine exam or screening procedure
done in conjunction with a routine exam

HMO - Health Maintenance Organization. Patient has to select Primary Care Physician and the
PCP should be caretaker of the patient. If the patient need to see any speciality then the patient
should get the referral from the PCP. Otherwise the patient has to pay high

PPO - Preferred Provider Organization. Patient does not need to select PCP. Patient can got to
any provider within network or out of network. But the patient has to pay high out of pocket
expenses for out of network provider.

EPO - Exclusive Provider Organization. It is hybrid of both HMO and PPO. Patient does not need to
select PCP so do not need referral. But there is limited network of doctors and hospitals to choose.
This plans don't cover care outside your network unless it's an emergency.

Medicare eligibility

65 age or older
Disability
ESRD

What is Hospice
Hospice is a special way of caring for people who are terminally ill, and for their family. This care
includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital
Insurance).
GV Modifier
The GV modifier is used when a physician is providing a service that is related to the diagnosis
for which a patient has been enrolled into hospice. This physician is not associated with the
hospice, and is providing services as the attending physician.

GW Modifier
The GW modifier is used when a physician is providing a service that is not
related to the diagnosis for which a patient has been enrolled into hospice.
Service is not related to the hospice patient’s terminal condition.

What are the different Modifiers

25-Separately identifiable E&M service by the same physician on the same day of the
procedure.
26-Professional component. It is used to identify the physician services.
TC-Technical component.
50-Bilateral procedure. Bilateral procedure that are performed in the same operative session
51-Multiple procedure. When multiple procedure other than E/M services are performed in the
same session by the same provider. Additional procedure should be identified as 51 modifier.
59-Distinct procedural service. Physician may need to indicate that a procedure or service was
independent from other services performed on the same day. It represent different procedure or
surgery.
76-Repeat procedure by the same physician.
77-Repeat procedure by the another physician.
QW - Used to identify waived test. Clinical Laboratory Improvement Amendment

What is Capitation
It is a fixed dollar amount per plan member per month paid to providers regardless of the
medical utilization

ABN(Advance Beneficiary Notice) (Waiver of Liability):

A written notice given to the patient by the Provider in advance of any service or supply
furnished for which payment may be denied or reduced by Medicare as not reasonable and
medically necessary. This notification serves as protection for both the Provider and the patient.
GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice

Medigap
A Medicare Supplement Insurance (Medigap) policy, sold by private companies, can help pay
some of the health care costs that Medicare doesn't cover, like copayments, coinsurance, and
deductibles.

HOSPICE
⦁ A hospice is a public agency or private organization that is primarily engaged in
providing pain relief, symptom management, and supportive services to terminally ill people and
their families.
Durable Medical Equipment
⦁ Equipment that can withstand repeated use, is primarily and usually used to serve a
medical purpose, is generally not useful to a person in the absence of illness or injury, and is
appropriate for use in the home

Network and Non Network provider

Place of service

11-Office or Clinic
12-Home. Patient receives care in a private residence
21-Inpatient hospital
22-Outpatient hospital. Do not required hospitalization
23-Emergency room
31-Skilled nursing facility. Service related to medical, nursing
34-Hospice. Service for terminally ill patients.
65-ESRD. Dialysis treatment

Claim form: Box No: 17, 18, 20, 31, 32, 25

17-Referring provider
18-Hospitalization dates
19-Additional information
21-Dx codes
22-Resubmission code
23-Prior authorization number
24-Date of service, POS, CPT code, Dx Pointer, Charges, Referring provider
25-Tax ID
31-Provider signature
32-Service facility
33-Billing facility

What are the clearing house

Emdeon
Gateway
Centricity
Healthfusion

What are the software

ECW
Kareo
Centricity
Healthfusion
Officeally
Difference between NCD and LCD

National coverage determination - The NCDs are developed by CMS to describe the
circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline
the conditions for which an item or service is considered to be covered (or not covered).

LCD — LOCAL COVERAGE DETERMINATIONS

LCDs are always based on medical necessity and created by a carrier whether to cover a
particular service. They only apply to the area served by the contractor who made the decision

This is a policy that is put out by Medicare to determine which services are covered and which
are not. It has a list of corresponding procedures and diagnoses to tell you when services are
covered and when they are not
This is the same thing as an NCD, but on a local level. Medicare, Medi-Cal, and Medi-Caid all
contract with other local entities to process their claims for them. Each local entity has their own
LCD's for their specific geographic region.

Specialities:

Nephrology
Cariology
Internal Medicine

Global Period
A global period is a period of time starting with a surgical procedure and ending some period of
time after the procedure. Many surgeries have a follow-up period during which charges for
normal post-operative care are bundled into the global surgery fee.