Healthcare Analytics and Medical Billing Services

November 19, 2014 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Revenue Cycle Management

Medical billing services typically know how to dodge the manual errors, timing issues, and outright mistakes that frequently cause claim denials. (Denials due to ineligibility, missed filing deadlines, and plain old miscoding are common across all specialties.)

Avoiding these common claim errors will help reduce overall claim denials, but to really lower your rejection rate, your coders or medical billing company must have an in-depth understanding of the big picture.

Through healthcare analytics tools we can shed new light on denial patterns across many practices. These are the top five most commonly denied procedures and the payers’ associated reasons for denial. To help you keep these denials from slowing down your revenue cycle, we’re also sharing our common-sense wisdom on avoiding them.

99213 – Outpatient doctor visit, level 3

Reason Code: 18 – Duplicate claim/service

18 is the reason code you get when more than one claim has been submitted for the same item or service provided to the same beneficiary on the same date of service. Why is 99213 such a frequent offender for duplication? Because it’s such a frequently used code. If your staff or medical billing service is getting dinged with this denial you will need to scrutinize these group claims further to understand the true underlying reason for non-payment.

99214 – Outpatient doctor visit, level 4

Reason Code: 97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

Another common code, another frustrating reason. Keep in mind when coding an E/M coders the visit may be bundled by the payer with another code. If it shouldn’t be – and is appropriately performed separately from a commonly bundled procedure – don’t forget to add the 59 modifier for “distinct procedural service.”

36415 – Routine blood capture

Reason Code: 16 – Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.

The word “routine” before “blood capture” explains why a claim for this procedure often ends up missing information. Don’t fall into a trap of omitting important details on claims for run-of-the-mill procedures. Get a second set of eyes on every claim to make sure no crucial fields are left empty.

97110 – Therapeutic procedure, one or more areas, each 15 min

Reason Code: 96 – Non-covered charge(s)

Sadly, many payers fight tooth and nail to avoid paying for therapies – even when patients desperately need them. Never, ever slack on eligibility checks if you conduct therapeutic procedures at your practice.

99232 – Subsequent hospital care

22: This care may be covered by another payer per coordination of benefits

This denial typically indicates that the beneficiary has another insurance company on file… so are your files on the patient up-to-date? Contact the patient to determine if any change has occurred in his or her insurance status, then make the right revisions in the patient data. (And be sure to ask all your patients about coverage changes up front when they sign in at your office.)


Are you interested in learning more medical billing tips? Visit our blog!

Speak with a billing expert today!


Subscribe to Our Blog

Stay in-the-know on trends, best practices, and news affecting the medical billing industry!