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Some providers are experiencing high-volume denials based on idiosyncratic edits, made-up rules, and black-box edits.

I have lost count of the number of publications released this year addressing surprise billing, incorrect use of Modifier 59, over-documentation, note bloat, billing for unnecessary services, over-prescribing of opioids, and myriad other topics targeting physicians. 

Some of the opinions and accusations are true. However, many are misleading messages designed to justify non-payment of legitimate, medically necessary services. Even more challenging is the resurgence of proprietary, black-box edits that withhold logic from physicians and their coding and billing entities. Although some of these issues do vary by geographic location, just a few examples of these payment denial schemes are outlined below.

For extremity orthopedic surgery, a post-operative pain block is a wonderful benefit for the patient. It can provide hours of pain relief and significantly reduce the need for narcotic medication. The authoritative coding guidelines permit billing the post-operative pain block, in addition to anesthesia services, when it was not the anesthesia for the surgery itself and was specifically ordered by the treating surgeon. When the requisite criteria are met, it is correct to code and bill for both services. 

Unfortunately, the much-maligned Modifier 59 is required. Numerous commercial payers are now utilizing edits provided by a third-party vendor, and routinely deny the post-operative pain block. When we appeal these denials with supporting documentation, the appeal is either denied, or in the case of CIGNA, the anesthesia payment is recouped, and the much more lower-cost pain block allowed. Perhaps our physicians should simply advise patients that their insurance plan will not pay for the most appropriate post-operative pain control care, and the treatment will unfortunately require an opioid prescription.

Many commercial plans have also begun using a third party to perform “audits” on a wide variety of procedures. I think that term may be a misnomer here. The definition of an audit is an official inspection of an individual’s accounts, typically by an independent body. When we have called the plans on these audit denials, many times we are told that no one has looked at the documents provided. It seems these are black-box edits, and not anything resembling an audit. Multiple industry sources have reported the automatic downcoding or denial of high level evaluation and management (E&M) services.

For interventional and surgical services, the denial explanations, if any, are often incorrect, or in direct contradiction to the authoritative coding guidelines. A recent glaring example was the denial of an interventional procedure, “because the ordering provider and performing provider were not the same.” Obviously, that would be far more common than not. We contacted the insurance plan on the issue. Per the Blue Cross response, they were unable to override a CHANGE audit finding, and we were required to appeal with an explanation. It seems that the ordering and referring physicians have the same last name but different first names, and that caused the denial! Who knew that different providers could not have the same name, if you expect payment!

The Centers for Medicare & Medicaid Services (CMS) introduced modifiers (XE, XP, XS, XU) to replace Modifier 59 by providing more details for certain CPT® code pair combinations. We implemented these modifiers, per the various commercial payer newsletters and instructions. In spite of following the physician education, claims began being denied. When we contacted UnitedHealthcare, the response was that although they recognize and directed use of the modifiers, two of the four were considered only informational, and were not adjudicated as equivalent to Modifier 59. Even more disconcerting, Humana has a pattern of denying every claim with a Modifier 59 or its equivalent.

This is the current environment for our physicians. They have high-volume denials based on idiosyncratic edits, made-up rules, and black-box edits. It requires enormous time and personnel resources to appeal and fight these denials of legitimate, medically necessary services. I don’t think what physicians are doing wrong should be the only hot-topic headline. I think the ever-increasing “proprietary” edits, audits, and denials should have equal billing as a cause of physician and patient dissatisfaction, escalating healthcare costs, and systemic problems that need to be addressed by the industry.

When proven, reproducible patterns of errors, based on authoritative coding guidelines, are identified, we should address the provider, rather than burdening the entire provider community and withholding just payment from the vast majority of physicians who do it right.

The punitive hammer the insurers hold needs to be addressed. They should not have impunity from wrongdoing.


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