From Care to Compensation, Part 2 -- From Claim to Billing
From Care to Compensation, Part 2 -- From Claim to Billing
Claim denials occur because of billing errors, as well as payer misbehavior when they edit claims for irrelevant reasons or make gross misjudgments about the service. These must be corrected and appealed.
Common denials are for lack of medical necessity, e.g., the diagnosis on the EKG or critical care code did not meet the payer's criteria, bundling one or more CPT codes into a single service (paying the visit code but denying the laceration repair as "bundled" into the visit), and "down-coding" (a higher level of service is reclassified by the payer to a lower level).
Denied Claims
Claim denials occur because of billing errors, as well as payer misbehavior when they edit claims for irrelevant reasons or make gross misjudgments about the service. These must be corrected and appealed.
Common denials are for lack of medical necessity, e.g., the diagnosis on the EKG or critical care code did not meet the payer's criteria, bundling one or more CPT codes into a single service (paying the visit code but denying the laceration repair as "bundled" into the visit), and "down-coding" (a higher level of service is reclassified by the payer to a lower level).
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