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Appeals Data Analysis

Part B Redeterminations

Claim denials are subject to Redetermination since a denial is considered a payment determination. A Redetermination is the first level of appeal after the initial determination on a claim. CGS staff involved with the initial claim determination does not complete the Redetermination.

There are some denials that can be avoided, thus reducing the need to request a Redetermination. Upon analysis of receipts, we found a number of common issues that, if billed appropriately, would save a lot of TIME and MONEY for you (by way of correctly processed claims upon initial submission), and would eliminate a substantial number of requests for us.

Please share this information with your coding and billing staff.

ISSUE

SOLUTION

Duplicate Services

When submitting the same service rendered on the same patient on the same date by the same provider, submit them on the same claim and use the UNITS field (electronic equivalent of Item 24G PDF of the CMS-1500 claim form) to identify multiple services were provided.

  • If services are submitted on separate claims or on separate detail lines of the same claim, they may deny as duplicate.
  • Be sure to submit bilateral services using one of the appropriate modifiers to avoid incorrect duplicate denials.

In cases where you absolutely cannot combine like services and submit them on the same claim, please use CPT modifier 76 or 91 on the subsequent service(s). Refer to the Modifier Finder Tool for details on these modifiers.
  • MUEs were created to reduce inappropriate payments that result from billing the incorrect number of units.
  • CMS published a MUE table External Websitethat includes the maximum units that may be billed on SOME codes. If you do not find the code in question on the table, it is confidential so it cannot be published. Check with your State and/or national specialty medical societies or associations for assistance.
    • Under the "Related Links" section, select the Practitioner Services MUE Table effective for the date of service in question, as the MUE values may be updated on a quarterly basis.

To prevent a duplicate denial when performing a medically necessary service that exceeds the MUE value:

  • Bill one line up to the MUE value;
  • Bill a second line (on the same claim) for the additional units and add CPT modifier 76.

If you received payment on a claim that needs to have additional units added, please request a Reopening of the claim to increase the number of units and billed amount of the claim (as long as the number of units does not exceed the Medically Unlikely Edit (MUE) value).

We are receiving Redetermination requests for incorrect duplicate denials with modifiers that are used to bypass the Correct Coding Initiative (CCI) edits. Using a CCI modifier to let us know the same service was performed multiple times on the same day will not pass our duplicate audit.

  • Please refer to the Modifier Finder Tool and review the information for CPT modifier 59, XE, XS, XU, and XP to learn more about CCI.

Concurrent Care Denials

In most cases, Medicare will pay for one service. A second service or procedure MAY be considered for payment only in unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the service feels another physician's expertise is needed.

  • In this situation, the second service performed on the same date of service should be submitted with CPT modifier 77.
    • Refer to the Modifier Finder Tool for details. Please be sure the patient's record support using this modifier.
  • If you've had a service deny for this reason, please resubmit the service with CPT modifier 77 (provided you have documentation to support using the modifier.)
  • You may also request a Reopening to add CPT modifier 77 to the service.
  • If the service still denies for Concurrent Care, please request a Redetermination and include documentation from each provider who performed the service.

This does not apply to Evaluation & Management (E/M) services. Please check here for information on concurrent E/M services.

Medicare does not pay for another interpretation for EKGs to be provided in the Emergency Room unless there is a questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed, or the diagnosis was changed as a result of the second interpretation.

  • When multiple x-rays and EKGs are performed in the Emergency Room setting, those services should be submitted with CPT modifier 76 (same physician) or 77 (different physician) as appropriate.
    • Please be sure the patient's record is documented appropriately.
  • A Redetermination is required for services denied for this reason.
    • When appealing this service, it is best to include the interpretation reports from each provider and/or an explanation of why the service had to be performed more than once.
  • Refer to the CMS Internet-Only Manual, Pub. 100-04, Chapter 13, Section 100.1External PDF for additional information.

This does not apply to Evaluation & Management (E/M) services. Please check here for information on concurrent E/M services.

Evaluation & Management (E/M services) - Denials may be prevented by including the following information with the initial claim submission:

  • Electronic claims: include the billing provider's sub-specialty designation (both the numeric AND narrative sub-specialty description are required) in either NTE 2300 Loop or Line NTE in the 2400 Loop
  • Paper claims: include the billing provider's sub-specialty designation in Item 19
  • The claim line diagnoses listed should be specific to the reason for the billed visits

Please check here for information on concurrent E/M services.

Redeterminations and Overpayments

Please be sure all departments within your organization are in agreement with how to handle claims and appeal requests.

SCENARIO: We process and pay a service. The provider's Finance department feels the service was paid in error so an unsolicited refund request is submitted to CGS. The billing department receives the remittance where the refund was applied and they request a redetermination stating the service was necessary.

Coordination among all departments is very important. In this scenario, please submit a new claim instead of requesting a Redetermination.

Denials Based on a Local Coverage Determinations (LCDs)

Reference our Local Coverage Determinations (LCDs) to check coverage and frequency limitations, if applicable. Our LCDs indicate our definition of medical necessity, identifying allowed CPT/HCPCS and ICD-10 codes.

For faster processing, claims that have been denied may be filed as new claims if you have a corrected diagnosis code. Please request an appeal if the medical record does not support a different (allowed) diagnosis code, but you have other documentation to support payment of the service.

Date of Service of Pathology Services

In situations where the provider did not perform a global path service but instead performed only one component, the date of service for the technical component (HCPCS mod TC) would be the date the patient received the service. The date of service for the professional component (CPT mod 26) would be the date the review and interpretation are completed. Refer to MLN Matters SE17023 Guidance on Coding and Billing Date of Service on Professional ClaimsExternal PDF for additional information.

Tips and Reminders

  • Please do not submit a Redetermination request to "correct a claim." The Reopenings process is more appropriate to correct minor errors or omission on previously processed claims.
  • Redetermination requests must contain medical documentation for each service being appealed. Multiple radiology or lab services require documentation that supports each occurrence and/or records from each provider billing for that particular service.

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