Hopefully the person who does your billing and coding knows that a modifier is. Hopefully you know what a modifier is. That two digit code after the performed procedure can make the difference between payment and no payment.
I was at a medical association conference promoting my business as well as learning about changes within the specialty. No sooner did I introduce myself, a physician came over and said he had some questions for me about his billing. He started by explaining his current billing person has been doing the billing for many years, and the billing person has always done a great job, but for some reason the claims she bills are now being denied. The billing person doesn’t know why his Medicare claims are being denied and doesn’t know if there is any way to fix them. The physician asks if I am up to the challenge of determining why his claims are getting denied. With a smile, he lets me know that even his current biller couldn’t give him an answer.
I let the doctor know that I haven’t billed his specialty before, but I will look into his issue and get back to him. During a low point of the conference, I tucked myself away with my laptop and visited the infamous Medicare website and checked the national and local coverage determinations to see what I could find about this particular specialty. This physician had denials on his chiropractic manipulation claims and Medicare has many specific rules on what a chiropractic claim must contain to be eligible for payment. The doctor was unaware that modifiers must be used on all chiropractic claims. The modifiers will show whether the treatment was for an active illness or injury, or for maintenance therapy (which is never covered by Medicare). There are also specific diagnoses required for chiropractic treatment to be a covered benefit. The requirement of modifiers, and specific diagnoses in a certain order already create a headache, but claims must also include first visit date, injury dates and/or x ray dates are required to be on the claim (depending on which state the services are performed).
In less than 2 hours I was able to locate the physician at the conference, and give him a list of checkpoints that he could reference on his denied claims to determine if those were the areas that rendered his denials from Medicare. The doctor was happy to have some more information to see about correcting his claims and I was happy to help him, as well as learn about a new specialty.
A few days after the conference was over I received a phone call from that same physician. Once he returned home and was able to check his Medicare EOBs, he determined his biller had left off the modifier on all his claims. All the other information was correct for payment; the diagnoses were correct, the dates needed to be referenced on the claims were listed, but the two digit code after the procedure was left off on each claim. So now the physician knew what needed to be corrected to get his payments. This physician ended up asking to me complete his billing from that point on. I was happy to solve the issue and get a new client, but it brought up the same issue I have seen so many times. Why didn’t the biller check on his denied claims so he could get payment for his services?
I let the doctor know that I haven’t billed his specialty before, but I will look into his issue and get back to him. During a low point of the conference, I tucked myself away with my laptop and visited the infamous Medicare website and checked the national and local coverage determinations to see what I could find about this particular specialty. This physician had denials on his chiropractic manipulation claims and Medicare has many specific rules on what a chiropractic claim must contain to be eligible for payment. The doctor was unaware that modifiers must be used on all chiropractic claims. The modifiers will show whether the treatment was for an active illness or injury, or for maintenance therapy (which is never covered by Medicare). There are also specific diagnoses required for chiropractic treatment to be a covered benefit. The requirement of modifiers, and specific diagnoses in a certain order already create a headache, but claims must also include first visit date, injury dates and/or x ray dates are required to be on the claim (depending on which state the services are performed).
In less than 2 hours I was able to locate the physician at the conference, and give him a list of checkpoints that he could reference on his denied claims to determine if those were the areas that rendered his denials from Medicare. The doctor was happy to have some more information to see about correcting his claims and I was happy to help him, as well as learn about a new specialty.
A few days after the conference was over I received a phone call from that same physician. Once he returned home and was able to check his Medicare EOBs, he determined his biller had left off the modifier on all his claims. All the other information was correct for payment; the diagnoses were correct, the dates needed to be referenced on the claims were listed, but the two digit code after the procedure was left off on each claim. So now the physician knew what needed to be corrected to get his payments. This physician ended up asking to me complete his billing from that point on. I was happy to solve the issue and get a new client, but it brought up the same issue I have seen so many times. Why didn’t the biller check on his denied claims so he could get payment for his services?
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