Without a doubt provider coding errors are a top reason for rejected claims at Community Health Centers (CHCs). This shouldn’t be surprising. We all know that CHC providers are insanely busy and creating and presenting quality coding training is next to impossible. Hiring a certified coder is another option but that can be costly and finding/ retaining qualified people can be a challenge.

PMG’s coding team reviews client claim data to find patterns indicating denials caused by coding errors. When they identify the coding error they communicate with the client so the code can be corrected and the claim resubmitted for payment. If it seems like a training is needed, our team builds a presentation based on that CHC’s particular challenges and coordinates to present the training either online or in person at the center.

I spent some time with our coding team and we chatted about Code Linkage and Medical Necessity, which is definitely high on the list for coding errors that cause claim rejections. You know payers love to reject claims for that! Fortunately, they have trained quite a few CHC providers on this topic and today I will be sharing a quick ‘cheat sheet’ version of their wisdom!

Code Linkage

Code linkage is the verification that the diagnosis code and procedure code match up to support medical necessity for the procedure. Failure to link the codes can result in claim denials.

Medical Necessity

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. The way to provide proof of medical necessity is to indicate with the proper CPT code and ICD code.

Bringing it All Together

Every CPT code must be supported by a corresponding ICD diagnosis code that supports medical necessity for the procedure that was performed; connecting the procedure codes to diagnosis codes that indicate that the procedure was medically necessary. The CPT codes tell what the provider did and the ICD code supports why the service was done.

Examples

If the patient came in with a fever and sore throat, and your office billed for a urinalysis, then insurance may not pay for it. Payers would consider a urinalysis for a sore throat and fever mismatched. Payers may consider performing a urinalysis on a patient who is not having any urinary symptoms or problems not medically necessary

A claim for a chest X-ray might be denied if the only diagnosis listed is diabetes because that diagnosis does not indicate a medically necessary or valid reason for the X-ray.

Our Two Cents

As the healthcare landscape continues to transform and we further explore alternative payment methodologies the importance of documentation and coding will grow. Accurate and compliant coding with will have an ever-increasing effect on reporting and without a doubt, your bottom line. As PMG Co-Founder, Ray Jorgensen often says, “Get paid when you can as much as you can so you can give it away when you want to.”