CPT 91035 is not being paid by the majority of the insurance companies. We need to find out how to get this CPT code paid. Do we need to add a modifier, obtain additional prior auths? This is usually billed with CPT 43235. Even when its billed by itself it is being denied. Anyone knows what happen here?
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CPT 91035 is not being paid by the majority of the insurance companies- Why?
CPT 91035 is not being paid by the majority of the insurance companies. We need to find out how to get this CPT code paid. Do we need to add a modifier, obtain additional prior auths? This is usually billed with CPT 43235. Even when its billed by itself it is being denied. Anyone knows what happen here?
Outpatient coding, billing errors continue to lead to majority of automated denials
By Steven Andrews
Outpatient coding and billing errors lead to more than half of all automated denials by Recovery Auditors, according to the latest RACTrac survey from the American Hospital Association (AHA).
The survey of more than 2,500 hospitals, conducted during the third quarter 2015, found that 40% of automated denials were the result of outpatient billing errors, while 20% were due to outpatient coding errors. This is up 10% for the combined results from the third quarter 2014 survey.
However, for complex denials, 76% of hospitals nationally report incorrect MS-DRGs or other coding errors as the top reason for denials. Incorrect APCs or other outpatient coding and billing errors only lead to 4% of complex denials.
Nationwide, the average dollar amount of automated denials is up sharply from last year at this time, with hospitals reporting each at $ 1,056 in 2015, compared to $ 688 in 2014. The average dollar amount for complex denials has fallen from $ 5,618 in 2014 to $ 5,458 in the most recent survey.
The rate of hospitals with denials reversed during the discussion period has also fallen, from 52% in 2014 to 45% in 2015, along with the number of denials available for appeal, from 540,203 to 366,479 over the same time period. Claims overturned in favor of the provider after completing the claims process have also fallen from 70% last year to 62% in 2015.
For complete results of the survey, as well as an archive of previous surveys and the opportunity to sign up for future surveys, see the AHA’s RACTrac site.
Note: APCs Insider will not publish the weeks of December 25 and January 1 due to the holidays, so look for the next edition Friday, January 8. Thank you for being a loyal reader of APCs Insider and have a safe and happy holiday season!
Healthcare News: Majority of industry stakeholders find smooth transition to ICD-10, according to survey
ICD-10 implementation has gone smoothly for approximately 80% of attendees who responded to a survey during a recent webcast from audit, tax, and advisory firm KPMG.
For 28.3% of the 298 respondents to the November survey, the ICD-10 transition has been smooth, while 51.4% reported a few technical issues, but overall success with the new code set since October 1.
Another 11.1% reported complete failure since implementation and 8.6% said serious work was needed but they are surviving the transition. Respondents included healthcare staff related to IT, finance, and the clinical side.
While the transition has been relatively smooth for the majority of industry stakeholders, providers will need to dedicate more attention to the quality and specificity of clinical documentation to reduce rejected medical insurance claims, said Catherine O’Leary, KPMG managing director, in a press release.
KPMG asked attendees which of the following was the largest challenge they faced with ICD-10 implementation:
- Clinical documentation improvement and continuous physician education
- Increase in denials or rejected claims
- Reduced revenue due to coding delays or coding errors
- System testing and information technology fixes
Approximately 42% of the respondents noted all of the issues remain a challenge at their facility, while 11.1% said none of the issues would be their largest challenge.
Respondents are tracking a variety of key performance indicators following implementation, with many focusing on denials and rejections (18%) and accounts receivable (11.1%). Facilities are also tracking discharged not final billed accounts (5.6%) and CC and MCC capture (4.9%). A majority of respondents (60.8%) are tracking all four of these key performance indicators.