In this month’s Journal of AHIMA, KIWI-TEK’s article “Denial Prevention: Understanding Common Culprits and How to Avoid Them” explores reasons for coding denials and offers practices to promote optimal reimbursement. As our company’s vice president of coding operations, I had an opportunity to provide insights into the root causes of denials and recommendations for an effective denial prevention strategy.
Identifying Root Causes
Identifying the root causes of coding denials is essential to effective management and creating a proactive approach to denial prevention. Here are four common culprits to consider:
- Coding changes (new CPT or ICD codes): If codes are not routinely updated, coders are more likely to use outdated codes.
- Varying payer guidelines: Private payers and the Centers for Medicare and Medicaid Services can institute specific criteria for coding. Awareness of payer-specific guidelines is critical.
- EHR upgrades, conversions, and entire system transitions: Transitioning to a new system causes interruptions that require more edits.
- Revenue cycle outsourcing: When the revenue cycle is totally outsourced, an organization typically sees more denials.
Though denials remain a reality, taking proactive measures to address improper coding issues on the front end can help prevent denied claims. The JAHIMA article provides a detailed summary of top coding denials identified in the past year.
Creating a Denial Prevention Strategy
An effective denial prevention strategy includes a combination of identifying root causes and implementing the following proactive steps:
Build a dedicated edits and denials team. A team approach works best to conduct research, write appeals, and resubmit claims. Best practice is to establish specific queues such as medical necessity and clinical validation to route edits back to specialists to work the denials.
Provide ongoing training and education. To avoid common mistakes that cause denials, coders need access to resources on the latest coding updates and payer guidelines.
Identify top denials and work to prevent them.Look for patterns and trends such as targeted DRGs. Engage a second-level coding manager or auditor to review the case.
As healthcare moves toward value-based reimbursement, providers must do everything possible to determine why coding errors occur and how to prevent them. Persistence in preventing denials pays off.
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