Ways to AVOID an Appeal
1. Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.
2. Become familiar with Local Coverage Determinations (LCD).
3. Become familiar with National Coverage Determinations (NCD).
4. Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.
5. Document a repeat or duplicate service to reflect it is as a distinct and separate service. Failure to document a repeat or duplicate service will result in a denial.
6. Submit supporting documentation with the claim when certain modifiers e.g. 52 or 22 are appended to the service or when a LCD or NCD indicates documentation is required. Failure to submit the documentation will result in a denial.
7. Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.
8. The supporting documentation must include the rendering physician’s signature. Failure to provide a valid signature will result in a denial.
9. Enter the concise description of an unlisted procedure code (an NOC code) or a “not otherwise classified” code. Failure to describe the NOC or other scenarios listed below will result in a denial.
10. When Medicare is the secondary payer (MSP) the claim must include information from the primary insurer. Failure to include this information will result in a denial.