If you have been involved in coding and denials management at any point in your career, you know how defeating it can sometimes feel! Understanding the type of denial can help unroof the underlying cause and, in turn, strengthen your rebuttal. Let's look at the two most common types of denials- Coding denials and Clinical denials.
A coding denial may be sent for many reasons, but most often, it is not applying coding guidelines accurately. This can be sequencing of diagnoses incorrectly or applying an incorrect code. Coders should always be careful to follow the rules set forth in AMA’s Official Coding Guidelines for coding principal diagnoses and ensure secondary codes meet criteria for coding. Other reasons for coding denials include unbundling services meant to be billed together and billing for a non-covered service.
Clinical denials are an entirely different animal. When a clinical denial is placed, it is most often because documentation for a specific diagnosis is lacking or does not meet criteria set forth by the insurance company. Clinical denials may also be received for conditions that lack medical necessity or are considered experimental in nature.
One question often asked is “Should I fight these?” and the answer is not the same for each case. Facilities should have a physician advisor(s), coder(s), and CDI(s) review the record and collectively determine if the case was documented appropriately, coded accurately, and billed correctly. If the documentation supports the coding and billing, most definitely and 1000% Yes! you should fight the denial. If you find an area with a problem, work on that problem as a team. Education is the best foundation against denials.
- Keep following the HCCS blog for more tips regarding managing denials. Our next blog will focus on how to find insurance clinical criteria.
- If you would like to learn more about HCCS’s Denials Management Program, please visit www.hccscoding.com.
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