How to avoid an Appeal Tips-1

**Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.

** Become familiar with Local Coverage Determinations (LCD).
 
** Become familiar with National Coverage Determinations (NCD)

** Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.

** Document a repeat or duplicate service to reflect it is a distinct and separate service. Failure to document a repeat or duplicate service will result in a denial.

** Submit supporting documentation with the claim when certain modifiers e.g. 52 or 22 are appended to the service or when a LCD or NCD indicates documentation is required. Failure to submit the documentation will result in a denial.

** Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.

** The supporting documentation must include the rendering physician's signature. Failure to provide a valid signature will result in a denial.

** Enter the concise description of an unlisted procedure code (an NOC code) or a "not otherwise classified" code. Failure to describe the NOC or other scenarios listed below will result in a denial.

** When Medicare is the secondary payer (MSP) the claim must include information from the primary insurer. Failure to include this information will result in a denial.

Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.

**  NPI of Billing Physician
**  Assignment or Non-assignment of claim
**  Health Insurance Number (HIC) of the beneficiary
**  Zip Code of the place of service
**  All related diagnosis reported with the highest degree of specificity
**  NPI of Referring Physician
**  Date of service
**  Place of service
**  Procedure code
**  Modifiers when applicable
**  Number of service(s)
**  Billed amount for each service
**  NPI of Rendering Physician
**  Clinical Laboratory Improvement Amendment Number (CLIA) for laboratory services
**  The date last seen/X-ray date, initial treatment date for Podiatry, Physical Therapy and Chiropractic services
**  Primary payer data

Become familiar with Local Coverage Determinations (LCD).

**  An LCD is a decision by a Medicare contractor whether to cover a particular item or service.  LCDs contain âœreasonable and necessary information and are administrative and educational tools to assist you in submitting correct claims for payment.

**  LCDs are located in the Medical Policy Center on the Novitas Solutions website.
Become familiar with National Coverage Determinations (NCD).

**  The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on §1862(a)(1) of the Act (the “not reasonable and necessary❠exclusion) unless otherwise specifically noted.