The Five-Step Process for Denied Claims
1. Determine that the service is medically necessary.
2. Provide the service needed in order to properly meet the patient’s needs.
3. Document the service provided.
4. Select the most appropriate CPT/HCPCS code for the medically necessary service that was provided and properly documented.
5. Submit the service to Medicare that was medically necessary and documented.
Check Your Records for the Following:
• Records are legible; reasonable clinicians will easily recognize all abbreviations and symbols.
• The patient’s name and the date of service appear on every page of the record (including the back side of double-sided forms).
• The date of service on the record matches the date of service on the claim.
• The medical record clearly indicates the identity and professional credentials of all people who contributed to the service and/or the record, and who contributed which portion(s) of the service and/or record.
• Information in the record clearly supports all diagnoses reported on the claim.
• Information in the record clearly demonstrates that all of the work described by the code(s) and/or modifier(s) reported on the claim was performed.
• All procedures reported are clearly documented.
• Evaluation and Management (E/M) services reported on the same day as a procedure are clearly documented, medically necessary, significant and separate from the procedure.
• The record of services performed “incident to” a physician service demonstrates the link between the employee’s work and the physician’s service.
• The record of services split/shared by a physician and non-physician practitioner demonstrates the face-to-face encounter and contribution to patient management by each practitioner involved.
1. Determine that the service is medically necessary.
2. Provide the service needed in order to properly meet the patient’s needs.
3. Document the service provided.
4. Select the most appropriate CPT/HCPCS code for the medically necessary service that was provided and properly documented.
5. Submit the service to Medicare that was medically necessary and documented.
Check Your Records for the Following:
• Records are legible; reasonable clinicians will easily recognize all abbreviations and symbols.
• The patient’s name and the date of service appear on every page of the record (including the back side of double-sided forms).
• The date of service on the record matches the date of service on the claim.
• The medical record clearly indicates the identity and professional credentials of all people who contributed to the service and/or the record, and who contributed which portion(s) of the service and/or record.
• Information in the record clearly supports all diagnoses reported on the claim.
• Information in the record clearly demonstrates that all of the work described by the code(s) and/or modifier(s) reported on the claim was performed.
• All procedures reported are clearly documented.
• Evaluation and Management (E/M) services reported on the same day as a procedure are clearly documented, medically necessary, significant and separate from the procedure.
• The record of services performed “incident to” a physician service demonstrates the link between the employee’s work and the physician’s service.
• The record of services split/shared by a physician and non-physician practitioner demonstrates the face-to-face encounter and contribution to patient management by each practitioner involved.
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