For the January edition, RemitDATA's chief operating officer, Brian Fugere, explores the most common unexpected denials, with a focus on orthopedics.
The data represented was collected from electronic remittance claim service lines between Oct. 19, 2013 and Jan. 16, 2014.
In this month’s summary of activity, the top five denied procedures across all specialties should not be a surprise, according to Brian Fugere, chief operating officer for RemitDATA; these are E&M office visit procedures (99213 and 99214) and seasonal procedures. As the flu and cold season began, routine blood draws (36425) and immunization administration (90471) worked their way into the top five. Lipid panels (80061) came in fifth, potentially indicating an increase in end-of-year routine physicals as annual insurance balances needed to be consumed.
From a denial reason perspective, the top five denied reason codes indicate potential process issues may be impacting a physician’s ability to get paid, said Fugere. Most of the top five reason codes revolve around adherence to payer rules when forming and submitting a claim. These process-related issues are usually relatively easy to solve within a practice through additional training.
Focusing on orthopedics for this month, Fugere noted that the three of the top five denied codes are all related to office visits (99213, 99214, and 99203). Codes for joint or bursa aspiration/injection (20610) and therapeutic exercise (97110) round out the top five. Again, the top five denial reason codes indicate possible non-conformance with payer rules, which can be overcome through diligent monitoring and training.