What are your first steps when analyzing a denied claim due to coding?

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First Steps When Analyzing a Denied Claim Due to Coding

1. Review the Denial Reason:
   Carefully read the denial code and explanation from the payer. This gives specific clues on why the claim was denied (e.g., incorrect code, lack of medical necessity, modifier issues).

2. Verify the Submitted Codes:
   Check the CPT/HCPCS, ICD-10, and modifiers on the denied claim. Ensure they are accurate, valid for the date of service, and correctly linked.

3. Cross-Check Clinical Documentation:
   Compare the submitted codes against the patient’s medical records. Confirm that documentation supports the level of service and diagnosis codes billed.

4. Check Payer Policies and Guidelines:
   Review the payer’s coding rules, Local Coverage Determinations (LCDs), and billing guidelines related to the denied service. Some denials arise from policy restrictions or coverage limits.

5. Identify Common Errors:
   Look for frequent issues like:

   • Upcoding or downcoding

   • Missing or incorrect modifiers

   • Unbundling of codes

   • Mismatched diagnosis and procedure codes

6. Recreate the Claim:
   If errors are found, correct the codes or modifiers and prepare the claim for resubmission.

7. Document Findings:
   Keep detailed notes on the denial cause and steps taken to resolve it for future reference and audit purposes.

Summary:
Start by understanding the denial reason, verify codes and documentation, check payer rules, identify errors, and correct before resubmitting. This systematic approach improves claim acceptance and revenue cycle efficiency.

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