ISSUE 3: Protect Your Assets

CODING ADVISOR

Curing Claim Denials

AAO members share their experiences with claim denials and how they were remedied.

SUE VICCHRILLI, COT, OCS, OCSR

A collaboration between Retina Today and

Fourteen days. That’s how long most insurance providers take to pay a clean claim—defined as a claim that has been submitted with the correct Current Procedural Terminology code, linked to the payable ICD-10 code and, when applicable, the correct modifier and place of service.

When a claim is denied, payment time is extended while the cause of the denial is researched. Then, once the claim is corrected by either phone review or resubmission, there is another 14-day wait for payment. The five examples below are true cases from American Academy of Ophthalmology members who share their experiences in the hope that other practices will not be subject to the same costly denials.

CASE NO. 1

CAUSE

First Coast Service Options, the Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the US Virgin Islands, is denying retina OCTs on new patients referred to us. The denial states, “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.” The referring physician has apparently already performed his or her own OCT.

CURE

Obtain an Advance Beneficiary Notice from the patient and append modifier -GA to 92134. Why? The First Coast Local Coverage Determination (LCD) for scanning computerized ophthalmic diagnostic imaging (SCODI—better known as OCT in clinical language), effective January 25, 2018, contains the following language regarding frequency: “No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment. These conditions include wet AMD, choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema. With the development of treat and extend protocols for patients with wet AMD treated with antiangiogenic drugs, it is expected that SCODI (unilateral or bilateral) will be used for therapeutic decision making and utilized at a maximum of monthly with subsequent less frequency based on the patient treatment protocol and patient response as documented in the medical record.”

The remittance advice will notify the patient and practice that either the test is covered or the patient is responsible for payment.

To read the entire LCD, visit aao.org/lcds under First Coast.

OTHER CAUSES FOR CLAIM DENIAL

Below are some other common causes for physician claims to be denied by payers.

  • Patient’s insurance changed and the practice was not notified, nor did the practice confirm insurance at the last appointment
  • No preauthorization was obtained as required
  • Injection of anti-VEGF drug was sooner than 28 days
  • Modifier was wrong or missing
  • Diagnosis was incorrectly linked to CPT codes
  • Tests were deemed by commercial payer to be “experimental” (ie, not a covered benefit)
  • Surgery was denied as “not medically necessary,” indicating that the practice selected a diagnosis that the payer hasn’t assigned to the specific CPT code used

CASE NO. 2

CAUSE

A bilateral injection for bevacizumab (Avastin, Genentech) was submitted as follows:

  • 67028-RT and J9035 for H35.3213 Exudative age-related macular degeneration with inactive scar, right eye
  • 67028-LT and J9035 for H35.3221 Exudative age-related macular degeneration with inactive choroidal neovascularization, left eye

The denial stated, “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.” The right eye was paid. The left eye was denied. The practitioner had seen the patient several weeks ago, a long time past the 28 days minimum frequency.

CURE

The first rule of coding is: know the payer. For Medicare patients all bilateral surgeries performed after April 1, 2013, must be submitted as a single line item with modifier -50. Do not reduce your fee. Medicare will correctly pay at 150% of the allowable. Commercial payers that do not adhere to Medicare rules will require two lines with -RT and -LT. Correct payment for all bilateral surgeries is 150% of the allowable.

CASE NO. 3

CAUSE

It seems that each payer requires a different Healthcare Common Procedure Coding System (HCPCS) J code for bevacizumab. A problem occurs when a patient has coverage from two insurance carriers, and one payer requires one J code and the second requires a different code. As a result, the second or supplemental insurance denies payment. With phone reviews and appeals, the process costs us more than the payment is worth. Can’t there be a single HCPCS J code?

CURE

There isn’t an actual cure for this one. Because ophthalmic use of bevacizumab is off label, it can’t have an assigned J code. Practices must continue to contact each payer for claims that automatically cross over.

Options are J9035, J3490, J3590, J7999, and/or C9257. Submit 1 unit for office-based procedures, 5 units for facility-based procedures.

For a list of all payer HCPCS options, look under Coding for Injectable Drugs at aao.org/coding.

CASE NO. 4

CAUSE

A few commercial payers are still denying appropriate ICD-10 codes for vitrectomy surgeries, stating that they follow the National Coverage Determination policy. This policy has been corrected, and yet the denials keep happening.

CURE

CMS has asked to be notified if practices continue to see denials from commercial or Medicare Advantage payers. Notify your MAC representative or contact Centers for Medicare & Medicaid Services at 1-800-Medicare if this occurs.

For background information on the current status, visit aao.org/vitrectomy.

CASE NO. 5

CAUSE

A patient underwent panretinal photocoagulation in the right eye. The claim was paid correctly. The left eye was treated outside the 10-day global period. Payment for the left eye was denied. The patient has commercial insurance.

CURE

Although Medicare changed its global period from 90 to 10 days, this commercial payer has not. It remains a 90-day global period. Submit with modifier -79 and -LT indicating that the second eye surgery is unrelated to the first. Payment should be 100% of the allowable. A new global period begins.