Diagnostic Radiology Claims: Most Common Reasons for Denials - Learning from the Mistakes of Others
October 23, 2007
Medicare contractor Trailblazer Health Enterprises recently issued a list of its top reasons for denying or rejecting diagnostic radiology claims between March and June 2007. Even if it isn't your payer, you may want to review this information with an eye toward your own history of denials, and take steps to ensure that you reduce them.
Most importantly, be sure to check with your own Medicare payer for resolutions to your individual claim rejection reasons.
Duplicate of a previously processed claim, which are often denied because: 1) the claim was previously processed (i.e., no payment was made, the allowed amount applied to the deductible on the initial claim, provider refiles a claim to correct initial claim, claim submitted again in error). 2) Provider automatically refiles a claim to seek payment if initial claim has not paid within 30 days.
Payer does not cover claim because the patient is enrolled in a health maintenance organization (HMO) (i.e., Medicare Advantage or replacement plans) or Medicare+Choice. Because beneficiaries can enroll in, and disenroll from, the above plans annually, physician offices should verify the patient's eligibility before seeing the patient.
The payer does not deem non-covered services as medically necessary. Check local coverage determinations (LCDs) for procedure-to-diagnosis code editing, and verify the service ordered against the LCD to determine whether the patient's diagnosis or condition meets medical necessity requirements. If not, advise patients of that fact and ask then to sign an advance beneficiary notice (ABN) if they wish to proceed.
Routine screening and related exams are not covered. Most preventive services are considered statutory exclusions from the Medicare program. Verify the purpose of the service, and if it was for screening, check whether Medicare covers it and if you billed it correctly.
Payment is included in another service received on the same day. The service was denied as a bundled service due to the national correct coding initiative (NCCI).