E&M medical necessity denials, what can that mean?

On the surface, what could not be right about an E&M code?

A lot of the rejections come from an office visit and another procedure performed on the same day. In many of the practices where we take over the medical billing, the physicians have lost money by not following the right protocols and/or not challenging the EOB. If the visit results in the second procedure, there is a modifier that is supposed (tongue in cheek) to tell the insurance company that this is a separately identifiable service and both services are to be paid. That being said, it does not mean you will get paid. Other denials often come from "we do not pay for two of these on the same day". It is important for the front office to ask if the patient has seen another physician on this same date. If so, unless it is emergent care, find out the policy of the patient's insurance company before seeing the patient. Otherwise you may just be giving away your services. The point here is to one; do your homework, and two; don't simply take the EOB at its face value, challenge it! Most physicians do not and the insurance companies love them because the insurance company gets to keep more of the physician's money in the process.

I have been told that every time an insurance company touches a claim, it costs them $150.00. Now just imagine for a moment if every time a physician got a rejected claim each and every physician challenged that claim, what do you think would happen? If you answered fewer rejected claims go to the head of the class! So don't just take their word for it, challenge it.

When the Correct Coding Initiative (CCI) was implemented, we were assured that everyone would have to abide by the same rules. The reality is significantly different.

Lately, Blue Cross of Georgia has changed its review policy. In the past for a pediatric patient that presented for a sick visit and needed a well check visit, we could bill both and get them paid. BC of GA now says they are using Anthem BCBS edit rules and will reject one or the other, and the rejection usually depends on which of the claims pays the most. We are still in the process of sorting it out but the physicians are looking at the contracts to see what recourse is available.

The sad part is that once again, it is the physician who must jump through all the hoops, follow all the rules and then not get paid.



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