The Art of Appeals
Presented by Lori Dafoe, CPC
Agenda
• Review what to look for in an
appeal, while reviewing an actual
example.
• Review different appeal process
for various insurance carriers.
• Review additional examples.
• Questions
Understand:
• Understand the denial.
• Understand what your provider is
billing and why.
• Understand basic coding principles.
• Understand the carrier’s
requirements.
• Understand your rights.
APPEAL
• Ask
• Probe
• Provide Evidence
• Explore
• Affirm
• Link
Ask
• Why is the claim being denied?
• NEVER assume.
ASK
Date
Proc
MD
Chg
Allow
Pymt
Adj
GRP
REM
12/23/
2013
92928
RC
$1,000
$0
$0
$1,000
CO
45
12/23/
2013
92928
LC
$1,000
$0
$0
$1,000
CO
203
12/23/
2013
93458
59
$625
$625
$625
$0
CO
203
ASK
Reason Code(s):
45
Charge exceeds fee schedule/maximum allowable or
contracted/legislated fee arrangement.
203
Discontinued or reduced service.
CO
Contractual Obligations
ASK
• Actual reason for non-payment:
Prior authorization required.
Probe
• Research to make sure it was
billed correctly.
Probe
• Review documentation for appropriate coding.
• Check for authorization.
• Review medical policy
Provide Evidence
• Use Medical Policy to refute
denial.
• Provide evidence to support your
stance (clinical studies, CPT
Assistant Articles, etc.)
Provide Evidence
• Knowledge of procedure.
• Policy allows payment for drug eluting stents
under certain conditions.
Explore
• Know the specific carrier’s appeal
process.
Explore
• Complaint can be made verbally or in writing. If
submitting in writing, specific cover sheet/form
must be completed.
• Level 1 Appeal may be submitted verbally or in
writing.
• Complaint and Level 1 must be submitted within
365 calendar days from the initial process date.
Appeal Letter
• Patient X underwent an angiography with
left heart catheterization and subsequent
stenting of the right coronary and left
circumflex (obtuse marginal branch).
Your company has denied payment for the
stenting based on a policy that indicates
prior authorization is required. The
purpose of this letter is to request a review
of the claim based on medical necessity,
and to ask that this policy for prior
authorization be assessed and revised.
Appeal Letter
• First, please note that although prior
authorization was not obtained, this service was
medically necessary. The patient has a prior
history of quadruple coronary bypass grafting
and stenting to the right coronary artery. He
presented to follow up from a hospitalization
where he had experienced new onset symptoms
of unstable angina. Due to his history,
symptoms, and the fact that he lives 133 miles
away from adequate treatment (Forks, WA), it
was determined that stress testing would not be
prudent, and the heart catheterization was
scheduled.
Appeal Letter
• Secondly, the policy indicates that drugeluting stents are considered medically
necessary when stents the length of 15mm
or longer are placed in a single vessel, or
for treatment of left main coronary
disease. The patient met both of these
criteria. The operative and prior office
notes are included for your review.
Appeal Letter
• Finally, we would like to request a Medical
Review of the policy in question (also attached
for your review). Prior authorization for this
service is not feasible. The provider does not
know if stenting will be required until after the
angiography/heart catheterization is performed,
nor can he tell where a possible blockage may be
or what percentage the vessel is occluded. To
either stop the procedure to obtain prior
authorization when needed, or stop the
procedure, obtain prior authorization, and
reschedule the stenting would put the patient at
greater risk for complications.
Appeal Letter
• For these reasons, we ask that you reconsider
payment for our claim, and revise the policy to
allow adequate care for our patients, your
beneficiaries. After careful consideration of the
medical record and supporting documentation
we anticipate the reversal of your initial decision
and issuance of payment in full for our claim. If
you have any questions or require further
information, please contact me. Should you
choose to deny this request, I ask that you send
written documentation including the criteria
and/or guidelines used to make your
determination.
Affirm
• Follow up!
• Take next step as needed.
Affirm
• Level 2 Appeal MUST be submitted in writing
and received within 15 calendar days from the
receipt of the Level 1 appeal denial
• Level 3 Mediation. Non-binding mediation may
be requested if there is a disagreement with the
second level of appeal. Mediation request must
be submitted in writing and received
within 30 calendar days from the Level 2
appeal notification. Mediator fees are shared
equally between both parties.
Link
• Document in the patient’s
account what you have done to
resolve the claim.
Link
• 01/14/14 Spoke to insurance rep. She could not
explain reason for denial. Will send back for
reprocessing. Biller A
• 01/18/14 Rec’d voice mail from insurance.
States denial was for no authorization. To coder
for review.
Biller A
• 01/25/14 Biller reviewed, coding accurate,
planned procedure, no auth obtained. To
compliance for review. Coder A
Link
• 01/25/14 Compliance reviewed, coding correct,
auth not obtained but service was medically
necessary. Disagree with prior auth policy.
Letter of appeal drafted and given to Biller A to
submit. Compliance Analyst A.
• 02/27/14 Appeal 1 denied. To Compliance for
review. Biller A.
• 02/28/14 Advised Biller A to submit Level 2.
Compliance Analyst A.
Link
• 03/21/14 Level 2 appeal denied. To Compliance
for review. Biller A.
• 03/21/14 Spoke with provider representative
regarding Mediation. Would like peer-to-peer
review between our cardiologist and insurance
medical director. Rep will call back to schedule.
Compliance Analyst A.
• 03/27/14 Rep called back, peer review scheduled
for 04/09/14 @8am. Compliance Analyst A.
Link
• 04/09/14 Peer-to-peer review completed.
Medical Director agreed. Will overturn denial
and allow payment. Will also take this to higher
level to make sure prior authorization policy for
cardiac services is reviewed and modified.
Reference number for call #1234 given to help
with any other denials we may receive until
policy is updated. Compliance Analyst A.
APPEAL
• Ask
• Probe
• Provide Evidence
• Explore
• Affirm
• Link
Appeal Process by
Carrier
• Aetna
• Cigna
• KPS
• Medicare
• Premera
• Regence
• United Healthcare
Aetna, cont.
• Timeframes for reconsiderations and appeals:
Aetna
Health care providers can use the Aetna dispute and
appeal process if they do not agree with a claim or
utilization review decision.
The process includes:
• Reconsiderations: Formal reviews of claims
reimbursements or coding decisions, or claims that
require reprocessing.
• Level 1 appeals: Requests to change a reconsideration
decision, an initial utilization review decision, or an
initial claim decision based on medical necessity or
experimental/investigational coverage criteria.
• Level 2 appeals: Requests to change a Level 1 appeal
decision.
Aetna, cont.
To help us resolve the dispute, we'll
need:
• The reasons why you disagree with
our decision
• A copy of the denial letter or
Explanation of Benefits letter
• The original claim
• Documents that support your
position (for example, medical
records and office notes)
Aetna, cont.
• Must have
member
complete a form
if filing an appeal
on behalf of the
member.
• http://www.aetna.com/faqshealthinsurance/documents/AuthorizedRepresentative-Request-Form.pdf
Aetna, cont.
• Mailing address for
reconsiderations for WA:
Aetna Provider Resolution Team
PO Box 14079
Lexington, KY 40512-4079
http://www.aetna.com/health-care-professionals/disputes-appeals/disputesappeals-overview.html
Cigna
• Time frame: 180 days
Cigna
• Requests for Claim Processing
Error/Missing Information vs.
Payment Appeal Process
Type of Claim
Address/Fax/PID
Guidelines
Corrected Claim
Paper: Address on back
of card.
Electronic: Submit to
Payer ID original claim
was submitted to
Paper: Claim form with
remarks .
Electronic: Update
Claim Frequency code.
Timely Filing Denial
Submit to claim address
on back of card.
Valid proof of timely
filing, such as the EDI
Acceptance Report for
electronic claim(s), etc.
Duplicate Submission
Submit to claim address
on back of card.
EOB or Claim Control #
of claim being disputed.
Reason for disputing
claim.
Incomplete Submission
Submit to claim address
on back of card.
EOB or letter requesting
additional info.
Additional info, such as
op report, test results,
etc.
http://www.cigna.com/assets/docs/health-careprofessionals/MM_002_appeal_request_for_provider_payment_review.
pdf
Type of Claim
Address/Fax/PID
Guidelines
No Authorization
Cigna ID: National
Appeals Unit (NAO) PO
Box 188011, Chattanooga,
TN 37422
Send EOB, Supporting
documentation, Reason
preventing prior-auth
from being obtained,
Completed Health Care
Professional Payment
Form (medical necessity)
Great-West ID: Great
West Healthcare PO Box
188062, Chattanooga, TN
37422-8062
Medical Necessity
Cigna ID: National
Appeals Unit (NAO) PO
Box 188011, Chattanooga,
TN 37422
Send EOB, Supporting
documentation as to why
decision should be
overturned, such as op
reports, medical records,
Great-West ID: Great
etc, Completed Health
West Healthcare PO Box Care Professional
188062, Chattanooga, TN Payment Form (medical
37422-8062
necessity)
Type of Claim
Address/Fax/PID
Guidelines
Mutually Exclusive,
Incidental, Bundling
Denials and Modifier
Reimbursements
Cigna ID: National
Appeals Unit (NAO) PO
Box 188011, Chattanooga,
TN 37422
Sent documentation that
supports by the decision
should be overturned,
such as operative reports,
medical records, etc,
Complete Health Care
Professional Payment
Appeal form
Great-West ID: Great
West Healthcare PO Box
188062, Chattanooga, TN
37422-8062
Contract/Fee Schedule
Dispute
Cigna ID: National
Appeals Unit (NAO) PO
Box 188011, Chattanooga,
TN 37422
Great-West ID: Great
West Healthcare PO Box
188062, Chattanooga, TN
37422-8062
Sent specific contract
element you disagree with
and a copy of the contract
page, Complete Health
Care Professional Payment
Appeal form
Type of Claim
Address/Fax/PID
Guidelines
Benefit Exclusion,
Limitation,
Administration (i.e.,
copay, deductible, etc)
Cigna ID: National
Appeals Unit (NAO) PO
Box 188011, Chattanooga,
TN 37422
Sent documentation
supporting why decision
should be overturned,
such as operative reports,
medical records, Complete
Health Care Professional
Payment Appeal form.
Great-West ID: Great
West Healthcare PO Box
188062, Chattanooga, TN
37422-8062
High Tech Radiology
(HTR) and Nuclear
Cardiac Services
MedSolutions
730 Cool Springs Blvd, Ste
800
Franklin, TN 37067
Sent documentation
supporting why the
decision should be
overturned, such as op
reports, medical records,
and reason preventing you
from obtaining prior
authorization.
Cigna/MedSolutions
• Access to Imaging Guidelines
requires login.
• https://www.medsolutionsonline.com/portal/se
rver.pt/community/medsolutions_online/223
Chest CT Denied (71260)
• PSR called Cigna, was told no
authorization needed. Given
reference number for call.
• Claim denied for no authorization.
• Two-fold appeal:
1.) Cigna Rep said no auth required.
2.) Service was medically necessary.
Chest CT Denied (71260), cont.
• Med Solutions denied as service
would not have been authorized
based on their clinical guidelines.
• Cigna denied because service was
not authorized.
Chest CT Denied (71260), cont.
• We are in receipt of a letter denying our
appeal for a CT of the thorax with
contrast. The letter admits that there
were extenuating circumstances that
prevented pre-certification in a timely
manner, but continues to deny based on
medical necessity. This letter indicates
that this is the final internal level of
appeal. We disagree with the manner in
which this claim has been handled and
are requesting special dispensations
regarding this unique claim situation.
Chest CT Denied (71260), cont.
• Please note that our scheduler contacted Cigna’s provider
customer service team to request prior-authorization
information. The representative mis-quoted the patient’s
benefits. We were told that no prior authorization was
required as the customer service representative sees this
group in your Medical module as PHS, which does not require
an authorization. However, upon further investigation it has
been determined that this group is actually PHS plus, which
does require an authorization. We were told to request an
authorization from Med-Solutions, which we did. This was
denied as Med-Solutions does not allow retroauthorizations. We then appealed the service with Cigna, and
the denial indicates the service was considered not medically
necessary. It further states that claim payment policies do not
allow for consideration of medical necessity once the
procedure has been completed except for cases considered
urgent with supporting documentation presented for review
by the Medical Director.
Chest CT Denied (71260), cont.
• First of all, I understand that Cigna
requires prior authorization from
MedSolutions, and we have done our
best to educate all staff members of
this. However, in this instance the
employee was covering in the
department and was not aware of this
protocol specific to Cigna. As such, she
called the telephone number on the
back of the patient’s insurance card and
was subsequently given erroneous
information.
Chest CT Denied (71260), cont.
• Secondly, please note the patient, who had
already been evaluated in the Emergency
Department, presented with complaints of
shortness of breath, and chest pain. Due to the
patient’s symptoms and family history of pectus
excavatum, Dr. Dawson ordered a CT of the
thorax with contrast. Attached, please find a
medical journal supporting the testing for this
condition. I have also attached a copy of the
patient’s office visit and subsequent CT results. I
have also included a copy of the front and back
of the insurance card, which you can see does
not specify MedSolutions must be contacted for
prior authorization of services.
Chest CT Denied (71260), cont.
• I understand that MedSolutions does not consider this test to be
medically necessary, but our physician did. Additionally, I have
provided a clinical case study in which CT is considered the best
diagnostic tool for symptomatic patients at rick of PE to estimate the
deformity and whether there are associated anomalies.
• In this instance, to not allow a peer-to-peer review because the service
was already performed is unfair. The service was performed in good
faith, based on the information given by the staff at Cigna.
• For these reasons, we are asking that the Medical Director review this
and after careful review of the medical record and supporting
documentation, we anticipate the reversal of your initial decision and
issuance of payment in full for our claim. Should you choose to deny
our request, I would like for you to send documentation outlining our
right to an independent review organization (IRO). If you have any
questions, or need additional information, please do not hesitate to
contact me.
Cigna, cont.
• Additional Appeal Options:
Arbitration
KPS
• Information can be found on the
paper remits, or on the KPS website
in the provider portal, under the
2014 KPS Practitioner Manual
• Timeframe: 30 days
• Good Faith Discussions
KPS, cont.
• Formal Appeal
• Address:
KPS Health Plans
Attn: Provider Complaints
c/o Provider Relations
PO Box 34262
Seattle, WA 98124-1262
KPS, cont.
• Mediation
• Address:
KPS Health Plans
Attn: Mediation
c/o Provider Relations
PO Box 34262
Seattle, WA 98124-1262
Layered Closure, CPT 12051 & 12031
• KPS denied claim for intermediate
repair of the cheek (12051) as being
included in the intermediate repair of
the scalp (12031-59).
• Although the codes themselves ARE
bundled, a modifier is allowed and
was used appropriately.
Layered Closure, CPT 12051 & 12031
• We are in receipt of a letter from your
company denying the charge for the
intermediate cheek repair. The remittance
indicates that the claim for the
intermediate repair of the cheek (12051)
was denied as being included in the charge
for the intermediate repair of the scalp
(12031). The purpose of this letter is to
request an appeal of that determination.
Layered Closure, CPT 12051 & 12031
• As documented in the operative note, the patient had
two cysts removed from the scalp requiring
intermediate repair; and one cyst removed from the
face requiring intermediate repair. Per coding
guidelines, a code for each excision was billed, with
the intermediate closures reported separately. Also in
accordance with coding guidelines, the sum lengths of
the repairs from the same anatomic site and same
classification (intermediate repairs of the scalp) were
added together to report the correct wound repair
code (12031). However, although the other repair was
also intermediate in complexity, the repair on the face
is listed under a different grouping of anatomic site
and was therefore reported with CPT 12051. Since
these repairs were of two separate anatomic sites,
requiring additional work, they should be reimbursed
separately.
Layered Closure, CPT 12051 & 12031
• Attached, please find a copy of the medical
record. After careful review of the medical
record and supporting documentation we
anticipate the reversal of your initial
decision and issuance of payment in full for
our claim. If you have any questions or
require further information, please contact
me. Should you choose to deny this
request, I ask that you send written
documentation including the criteria
and/or guidelines used to make your
determination.
Medicare - Reopening
Medicare - Redetermination
Medicare - Reconsideration
Medicare – Administrative Law Judge (ALJ)
Medicare – Appeals Council
(Departmental Appeals Board (DAB))
Medicare – Federal Court Review
Medicare
• Https://www.noridianmedicare.com/partb/
• Appeals
• Forms
Medicare
• CPT 97597: Debridement, open wound, first 20
sq cm or less
• ICD-9: 873.1: Complicated head/scalp wound
920: Contusion scalp
• Denied: CO-50 - Contractual Obligation. These
are non-covered services because this is not
deemed a “medical necessity” by the payer.
Medicare
• Diagnoses listed is NOT on the LCD; however,
the LCD specifically states, “CPT 97597 and
97598 may be used for medically reasonable and
necessary debridement when utilized consistent
with this LCD and within the scope of the
performing provider”.
Medicare
1. The service was medically necessary
2. The procedure performed was consistent with
the guidelines of the LCD, even if the specific
diagnosis was not listed.
3. The procedure performed was within the scope
of the physician’s practice.
Medicare
• Patient on blood thinners for a heart condition,
fell and hit her head resulting in devitalized
tissue from a complicated open scalp wound
requiring debridement down to the bone using
sharp scissors.
Medicare
• Medical necessity cited as non-viable tissue can
produce a noxious odor and frequently
unacceptable discharge. Devitalized tissue also
provides a culture medium for bacterial growth
and wounds containing necrotic tissue are
therefore at risk of becoming clinically infected.
Medicare
• Q2 Response: The service was denied because the facts
do not support a payable condition or diagnosis based on
LCD.
• You billed 873.1 for open wound of the scalp is not a
covered condition for this treatment according to LCD
L24374. Your records did support debridement of an
open wound an apparent devitalized tissue. Although
the diagnosis was not listed in the LCD, the records
support the services were reasonable and necessary for
the care and treatment of the beneficiary. Therefore, the
service can be allowed for payment as billed. The
documentation supports the service was reasonable and
necessary in accordance with Medicare guidelines.
Premera
Resolution Level
Date Requirements
Response Timelines
Complaint
365 days
30 days
Level I Appeal
365 days
Billing related - 30 days
Non-billing related – 60
days
Level II Appeal
15 Days from Level I
decision.
15 Days
Mediation
30 Days
Premera
Information can be found
by logging onto
OneHealthPort.
Premera
• CPT 92083, Extended Visual Field Test
• ICD-9: 374.87 Dermatochalasis
• Denied as not medically necessary
Premera
• Your company has denied our request for
reimbursement of a visual field test (CPT 92083) and
external ocular photo (CPT 99285) for derrmatochalasis
(ICD-9 374.87) stating the service is not medically
necessary. The purpose of this letter is to request an
appeal of that determination.
• Dermatochalasis is redundant and lax eyelid skin and
muscle. Dermatochalasis can be either a functional or a
cosmetic problem for patients. As in Mrs. X’s case,
functional dermatochalasis obstructs the superior visual
field. Because of the drooping upper eyelids, Mrs. X has
complained of having lift up her eyebrows in order to see
better. As the condition worsens, blepharoplasty may be
required to correct this.
•
Premera
• The Premera medical policy for a blepharoplasty surgery to
correct this condition requires that the patient have
documented visual defects to specific degrees. In order for us
to determine the severity of Mrs. X’s visual function, we had
to perform the extended visual field test (CPT 92083) and the
external ocular photo (CPT 92285). Because this service was
provided in relation to a functional problem and not a
cosmetic service, we must ask that you reconsider payment for
this claim.
• Attached, please find a copy of the medical record
documenting the service provided and the subsequent
findings. After careful review of the record and supporting
documentation we anticipate the reversal of your initial
decision and issuance of payment in full for our claim. Should
you choose to deny this claim again, I would ask that you send
written documentation listing the criteria used to make your
decision.
Premera
• Denials of medical necessity based on “Milliman
Care Guidelines”
• CPT: 58550 - Laparoscopy, surgical, with
vaginal hysterectomy, for uterus 250 g or less;
• ICD-9: 627.0 - Premenopausal menorrhagia
Excessive bleeding associated with onset of
menopause
Regence
• http://www.wa.regence.com/provider/claimsand-billing/appeals/
• Timeframe: Within 12 months after payment of
the claim or notice that the claim was denied.
Regence
• Reconsideration requests for Medical and
Reimbursement policies (not related to a claim)
may be submitted using the
1.) Medical Policy Review Request process
2.) Reimbursement Policy Request for
Review process
• Administrative Denial Appeals
Regence
http://www.wa.regence.com/provide
r/library/form/docs/provider-billingdispute-appeal-form-washington.pdf
Regence – Audit Appeal Process
• Appeal form for Provider Billing Disputes and
Medical Necessity denials may be submitted via
facimile to (866) 273-1820. Large documents or
information sent certified should be mailed to:
Regence
Attention: Provider Appeals
PO Box 1239
Portland, Oregon 97207
Regence – Audit Appeal Process
• Information to submit:
1.) A detailed description of the disputed
issue(s);
2.) the basis for disagreement with the decision;
and
3.) All evidence and clinical documentation
supporting your position.
Regence – Audit Appeal Process
• A written decision on an Internal Review of an
Adverse Determination appeal will be sent
within thirty (30) calendar days of receipt of all
documentation reasonable needed to make the
determination. A description of the External
Review option will be supplied with the written
decision, including the time limit for requesting
External Review.
Regence – Audit Appeal Process
• If initial determination is upheld, you have the
option to seek External review or one of the
other dispute resolution processes. The time
limit for requesting External Review is ninety
(90) calendar days after the written Internal
Review determination.
Regence
• Voluntary binding external review
• Amount in dispute must exceed $500.
• Adverse Determination Appeal must be
submitted in writing.
• Provider pays $50.00 filing fee for each Adverse
Determination Appeal
• Fee must be submitted within sixty (60)
calendar days of notice that fee is due.
• External Review Organization will process and
notify of recommendation within thirty (30)
calendar days of the filing fee.
• Decision is binding on both parties.
Regence
Regence
• Went through Internal Review/Appeal, requested
External Review.
• Received Approval of Procedure Codes as Submitted
by Provider
• Rationale for approval of code: “29822 is an
Arthroscopy, shoulder, surgical debridement,
limited. 23430 is a Tenodesis of long tendon of
biceps. These two procedures do not have an NCCI
edict indicating that they are bundled; also they are
two entirely separate procedures, one done with an
arthroscope, and one with an open incision. 29822
is separately reimbursable.”
Regence AIM Clinical
Guidelines
• http://www.aimspecialtyhealth.com/
clinical-guidelines/agreementAccess
CPT 74175: CTA, abdomen with contrast
• Claim denied as authorization number obtained
was for regular CT scan, not CTA. AIM refused
to retro-auth procedure.
• Regence representative said that since AIM did
not make an error they would not entertain any
other reason for appeal.
• Scheduler thought CT venogram was just a
regular CT angiogram. As such, service was preauthorized as a regular CT scan (CPT 7417674178), instead of CPT 74175. Education
provided to staff member, but payment should
still be made for this medically necessary
service.
• AIM Clinical Appropriateness Guidelines state
CTA of abdomen is allowed for suspected
renovascular hypertension from renal artery
stenosis for patients on therapeutic doses of 3 or
more anti-hypertensive medication.
• Patient presented to vascular surgeon with chronic
massive lower extremity edema. Also has very
difficult to treat hypertension and is currently on 5
medications.
• Exam revealed bilateral 4+ lymphadema. Right and
left leg Doppler exams indicated biphasic flow.
Venous ultrasound was performed and deep venous
reflux was identified in the right common femoral
vein. Reflux could not be noted in the right or left
great saphenous vein due to obesity and edema.
However, reflux was suspected because of multiple
enlarged tributatries, and increased diameter of the
saphenous vein and the patient’s symptoms of
swelling.
• Multiple possibilities considered in the
differential diagnosis of peripheral edema,
including lymphadema praecox, venous
obstruction, venous reflux, lymphatic
obstruction. The CTA of the abdomen was
ordered to determine the cause of the edema.
• No venous or lymphatic obstruction noted on
CTA performed; however there was a lesion
noted in the pancreatic tail, inflammatory
changes in the superior mesentery and a large
3.2 cm mass in the superior mesentery that
could represent an enlarged and necrotic lymph
note, mesenteric metastasis, or even aneurysm.
• Because the patient had a previous pancreatic
biopsy, the enlarged lymph notes were present
on the CTA were worrisome for metastatic
disease, the patient was referred to hematology
oncology as a possibility of a retroperitoneal
malignancy could manifest as lymphadenopathy.
• Although prior authorization was not obtained
for the correct study, the service was medically
necessary and would have been approved
according to AIM’s guidelines.
UHC
https://www.unitedhealthcareonline.co
m/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/Provider
StaticFilesPdf/Claims%20&%20Payme
nts/Combined_Claims_reconsideration
_paper_form_and_guide.pdf
UHC, cont.
• Paper Claim Reconsideration requests:
United Healthcare and United Heathcare West:
Address on EOB, PRA or claim address on
back of member’s ID Card
UnitedHealthcare Empire Plan: PO Box 1600
Kingston, NY 12402-1600
UHC, cont.
• Online Claim Reconsideration – Quick
Reference
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Help/ClaimReconsider
ationQRC.pdf
UHC, cont.
• CPT 99203-57 – New Patient, Level 3,
Outpatient
• CPT 46060 – I&D of ischiorectal abscess or
intramural abscess, with fistulectomy,
fistulotomy, submuscular, with or without
placement of seton.
• Claim denied, and 1st Level Appeal Denied,
stating services described by CPT code 99203-57
are included in the global service package for
CPT code 46060.
UHC, cont.
• We are in receipt of your letter denying our Level
I Appeal for an E&M service on the same day as
a major procedure. The purpose of this letter is
to request a second level appeal. We further
ask that a board certified physician of
like specialty review this claim.
• Attached, please find the documentation for the
physician’s office visit. Dr. Y had to do a full
work up on this patient to determine the
appropriate treatment for this patient, which
resulted in a major procedure.
UHC, cont.
• Your letter states, “UHC considers the Current
Procedural Terminology (CPT) manual to be the
industry standard reporting convention including
when a physician submits multiple CPT codes for
services to the same patient. However, UHC does
not believe this reporting convention determines
what physicians should be reimbursed in all
situations… Our clinical staff has reviewed your
appeal and determined that the services described
by CPT code(s) 99244-57 are included in the global
service package for CPT code 46060.”
UHC, cont.
• An E&M service provided the day before or the
day of a major surgery that results in the initial
decision to perform that surgery, should be
eligible for reimbursement when modifier -57 is
appended to the E&M code. A major surgery is
defined as having a 90 day global period as
assigned by Centers for Medicaid and Medicare
Services (CMS).
UHC, cont.
• It is a fact that the relative values for surgeries do not
include the initial E&M service, where the decision for
surgery is made, and is therefore not included in the
global service package. Additionally, according to both
CPT and Medicare, the decision for surgery is not part of
the surgical package and should be separately coded
using an E/M code. Because the –57 modifier indicates
more involved medical decision making on the
physician’s part, the carrier should not take exception to
paying for the separate encounter on the same date that
the procedure or surgery was performed. Your letter
also indicated that “UHC’s policies seek to fairly and
appropriately reimburse physicians for services
performed”. We ask that you follow industry standards
with regard to the -57 modifier and the appropriate
usage of this as identified by both CPT and CMS
guidelines by paying us “fairly and appropriately”.
UHC, cont.
• In our previous appeal we requested that you
provide documentation to support your decision.
Your letter states, “…UHC seeks to take into account
many relevant factors including, where appropriate,
the views of specialty societies, consultants and the
Centers for Medicare and Medicaid Services…”.
Should you choose to deny this request for payment,
I again ask that you send written documentation
supporting your decision; specifically your
policy/criteria used to determine when your
company will allow payment for an initial
evaluation and management service where
the decision for surgery is made.
Examples
DOS
CPT
Charge
Payment
Remarks
03/18/2014
26123
2,000.00
0.00
CO4
Adjust Codes
CO4 – Contractual Obligation. The procedure code is
inconsistent with the modifier used, or a required modifier is
missing.
CPT 26123 - Palmar fasciectomy and release small finger contracture.
Review of documentation revealed patient underwent same procedure on the
LEFT hand January 7, 2014. Still under global period from that surgery.
Procedure on 03/18/2014 was for RIGHT hand.
Examples
Examples
• Denial stated office used CPT Assistant article
from January 2005 to substantiate personal
bundling edits.
• Coder located article and did not believe carrier
was applying it correctly.
• Also found an article by AAOS to support coding.
Examples
• The CPT assistant article being referenced describes two
different paragraphs on the same type of procedures which
are done with different techniques.
• The section you are referencing to validate your denial is
discussing a base procedure (CPT 26447) not the suspension
arthroplasty (CPT 25447) which our provider performed.
• The article titled “Variation: Suspension Arthroplasty” clearly
states that when billing CPT 25447 it is appropriate to bill
either CPT 25310 or CPT 26480 in addition as the transfer of
the FCR to the base of the first metacarpal is not part of the
basic first CMC arthroplasty procedure and must be coded in
addition to the 25447. In addition to the above, our office has
located a bulletin from the American Academy of Orthopedic
Surgeons dated August 2005 which reinforces the above
determination stating that the tendon transfer is not bundled
into the arthroplasty procedure and should be allowed and
reimbursed separately.
Examples
• Unable to locate any documentation to support
this inappropriate McKesson bundling edit. I
have carefully reviewed the NCCI (National
Correct Coding Initiative) edits and this tool
does not bundle these services together. Because
of this, the addition of the modifier 59 would be
inappropriate as well as unnecessary and both
lines of this claim should be paid.
QUESTIONS?