Avoiding denial - claim review before submission

Common Problems and Solutions

When a denial or underpayment is received from a payer, it’s often necessary to review the original claim
submitted to the payer along with the EOB to identify and correct the problem. By doing this type of
analysis, you can determine if there was a simple coding error or if the denial was based upon
something else, such as the payer’s coverage policy on a specific procedure or product. Here are some
items to keep in mind when reviewing the original claim and EOB.

1. Original Claim Analysis

> Review the claim to ensure that all codes are complete and accurate

—ICD-9-CM codes are listed and coded to the highest level of specificity
(don’t use a truncated ICD-9-CM code when a more specific code is available)

—ICD-9-CM codes are linked to each service line on the claim form

—J and Q codes for drug products are listed and units are accurately billed

—CPT codes reflect the services provided during the patient encounter

—Modifiers are used as necessary

—The most recent volumes of each of the coding books are used as a reference;
out-of-date codes can result in denials
> Examine your charges; most payers will reimburse the lesser of their allowable or your charges

—Verify that date of service and place of service are correct

—Include correct names and provider identification numbers of both referring and treating
providers on the claim

—Be sure you’ve billed the right payer, especially if the patient has primary and secondary insurers

—Confirm you have the signature of the patient on file and the treating physician’s signature on
the claim