2024 Gastroenterology Reimbursement and Coding Update | November 2023-12 - Top Denials in GI and How to Avaoid

12 - Top Denials in GI and How to Avaoid _Vaughn

Pdf Summary

In this presentation, Kristin Vaughn discusses the top denials in gastroenterology (GI) and provides strategies to avoid them. She begins by highlighting the reasons why claims are being denied, despite the implementation of electronic health records (EHRs) and claim scrubbers. Vaughn emphasizes the importance of preventing denials and submitting initial clean claims to avoid the high cost of resolving denied claims.<br /><br />Denials cost an average of $6.50 to file, and resubmitting a denied claim can cost between $25 and $118. The cost to submit, correct, and resubmit a claim ranges from $31.50 to $124.50 per claim. Vaughn suggests that some denials are preventable by ensuring staff is educated on using Correct Coding Initiative (CCI) edits and documenting the locations and methods of treatment clearly.<br /><br />The presentation highlights several denial reasons for GI, focusing on bundling issues involving Modifier 59 or XS. Vaughn emphasizes the importance of thorough documentation and using diagnosis pointers on the claim to indicate specific procedures and diagnoses. She provides examples and specific instructions for properly using Modifier 59 or XS.<br /><br />Other denial reasons discussed include denials due to modifier 25 errors, place of service errors, lack of medical necessity or specificity, unacceptable primary diagnoses, and diagnosis code exclusions. Vaughn advises providers to educate their staff on payer requirements, document co-morbidities and risk factors, and ensure accurate and specific diagnoses are submitted on the claim.<br /><br />Lastly, Vaughn provides valuable tips for dealing with denials, including not assuming a denial is solely due to a coding error and researching the reasons on the explanation of benefits (EOB). She encourages providers to resubmit denied claims, involve patients in the appeal process, and utilize tools such as CCI policy, LCDs, and payer policies to support medical necessity.<br /><br />Overall, this presentation provides valuable insights and strategies for avoiding and resolving denials in GI, ultimately helping organizations improve revenue and cash flow.

Keywords

denials

gastroenterology

claims

EHRs

clean claims

CCI edits

bundling issues

thorough documentation

diagnosis pointers

resubmit denied claims