Was Your Claim Denied as a Duplicate Service?

On occasion (if not more often), every practice receives a notice of claim denial that reads, ‘duplicate service.’ When the insurance denies a service as duplicate but your records indicate that is not true, how should you act?

First, gather all pertinent information on the claim to determine a possible cause. The following are some reasons why the claim may be denied as duplicate:

Bill chronic care management (CCM) services on the last day of the calendar month the service was done. Therefore, if the service began in January, you would bill 99490 with the date of service as January 31. 

You cannot bill CCM for the care of a patient only due to having two chronic illnesses; to bill CCM, the chronic conditions must be showing significant risk of death, acute exacerbation, decompression or functional decline.

It is time to start improving your clinical documentation to prepare your practice for ICD-10.

Select the codes most often used in your practice. Now, you need to determine if your current documentation is sufficient to support ICD-10. It would be best to assume it is not, since ICD-9 was not as specific as ICD-10. For example, you did not need to include laterality, now you must include which side of the body is affected (i.e. right, left, or bilateral).

Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In an effort to aid in the preparation of this year, I have listed some common helpful tips that you might follow in order to best manage your workload ahead.

Evaluate fees: Fee schedules are often compared to peers. Practices should use a reliable source to evaluate fees annually to ensure that your fee schedule is consistent with statistical expectations.

What is a Gap Analysis?

A Gap Analysis is a process by which a practice conducts a baseline assessment of the company's coding, billing, operations, and business practices. The objective of a Gap Analysis is to ensure that the practice is in full compliance with applicable legal and ethical requirements. 

This performance measurement tool is used to determine which actions must be taken in order to bring the entity's practices up to the desired/required level of compliance. 

Anyone who uses modifier 59 needs to be aware that due to problems with the incorrect usage of this modifier (which by the way is also revised for 2015,) CMS has added four new HCPCS modifiers. An announcement by CMS stated that "CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” 

These new codes are:

MedScape is offering a free training activity for healthcare providers who will be involved in clinical documentation with ICD-10.  

This activity is to make providers aware of the key elements of good clinical documentation.

CME/CE Released: 09/15/2014; Valid for credit through 09/15/2015


 by Aimee Wilcox, MA, CST, CCS-P

Have you ever wondered when it is appropriate to document a comprehensive past medical, family and social history (PFSH) or if the necessity of doing so will be questioned during an audit?

Well, providers are concerned about how their documentation will hold up in an audit and since most haven’t been formerly trained in medical coding, their concerns over a potential audit are valid. 

Q: When is it appropriate to document a comprehensive past medical, family and social history?


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