Claim denials have been a major concern for foot and ankle surgeons as it affects reimbursement for surgical services. Denials may be due to inaccurate and improper coding, misspelling or missing information of procedures. Foot and ankle surgeons should always document services provided as being "medically necessary" in order to be payable. Coding properly has important legal as well as financial implications. For example, accurate evaluation and management (E&M) coding can help protect physicians from the financial and legal ramifications of a Medicare and managed care audits.

The top ten reasons for claim denials are the following:

1. Incorrect or missing ICD-9 diagnosis
2. Incorrect or missing modifiers
3. Duplicate claim
4. Additional information needed to process the claim
5. Billed amount is incorrect
6. Incorrect/missing CPT procedure codes
7. Physician's name and/or NPI number is missing or incorrect
8. Incorrect or missing place of service code
9. Incorrect or missing quantity multiples or services
10. Services are unbundled

So What Happens When a Claim is Denied?
When a payer denies a claim, a letter is usually sent listing the reason(s) for the denial. Foot and ankle surgeons should refer to the payers' guidelines on how to pursue an appeal. Insurers may request clarification about the use of a procedure or request that the surgeon document the medical necessity of a procedure. When a claim requires this kind of information, one or more of the following should be submitted:

• Letter of appeal: The payer may consider payment on a case-by-case basis if the physician submits a letter explaining why the patient should undergo a particular procedure or treatment. Be advised that even submitting a letter of medical necessity does not guarantee reimbursement.
• Clinical information on the procedure: The payer may need clinical practice guidelines or evidence-based medicine to verify if the procedure is "medically necessary" and not experimental. Examples of this type of information can be found in ACFAS' collection of clinical practice guidelines: http://www.acfas.org/pubresearch/cpg/ or at the National Guideline Clearinghouse at http://www.guideline.gov/.

How to Reduce or Eliminate Claim Denials

1. To assure that claims are approved, foot and ankle surgeons should carefully document medical records. If the level of service provided to the patient during an office visit is not reflected in the patient's record, then payers will consider the service not performed. Foot and ankle surgeons can prepare a template which reminds the physician which criteria must be established for each E&M service level and provide an easy check-off sheet to document during the visit.
2. Review and monitor denials and claim reductions carefully to determine patterns. Are problems caused by inaccurate patient information, identification numbers and claim numbers? Are there coding errors? If so, implement a system to cross- check filing claims.
3. Use ACFASCodingtoday.com or a coding reference sheet with a list of commonly used ICD-9 diagnosis codes and CPT codes, as well as any other commonly reported codes on the standard claim form. These tools can assist physicians and office managers in determining which CCI modifiers are allowed or what codes can be bundled.
4. Evaluate the health plan's explanation of benefits (EOB) for accuracy including potential processing errors or lack of recognition of a CPT modifier.
5. Know the contracted fee schedule rate with each payer for procedures and services commonly performed in the practice. Review each EOB received to ensure the negotiated reimbursement and discount rate with each health plan is calculated correctly.
6. Maintain a health plan follow-up log that contains the reason that the claim was partially paid, delayed or denied by the payer and also include the internal follow-up action by the practice staff to reduce future underpayments and denials.
7. Denied claims should be appealed! Though some physicians consider appeals an administrative burden, not appealing denied or partially paid claims can result in decreased revenue. When a practice increases its' appeals for wrongfully underpaid or denied claims, the payer may correct its claims editing software and processes which could result in improved claims processing and appropriate payment to the practice.
8. Keep staff trained on the latest billing requirements. Each staff member responsible for any aspect of the billing process should attend billing and coding seminars and other continuing medical education courses, such as the ACFAS Practice Management and Coding Seminar. Education of the staff on state and national insurance requirements, such as HIPAA and CCI edits, as well as establishing office policy and procedures are essential
9. Perform internal audits and follow up on any discrepancies with the office managers and billers.
10. Establish a relationship with the each payer and communicate with the appropriate health plan representatives within each plan's claims and appeals processes.

With accurate coding and documentation, foot and ankle surgeons and office managers can help expedite reimbursements from payers and ensure accuracy of patient records. Although the coding system may seem confusing, it is important to stay up-to-date on system changes and various guidelines. In the long run, it will save the practice money and prevent fraud-and-abuse concerns.