Code Encounters

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.  

Based on current COVID-19 trends, the Department of Health and Human Services is planning for the federal Public Health Emergency (PHE) for COVID-19, declared under Section 319 of the Public Health Service Act, to expire at the end of the day on May 11, 2023. Learn more at: https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf

Managing out-of-network denials refers to the process of addressing and resolving claims that are rejected by insurance providers due to the healthcare service being rendered by a provider who is not part of the insurance network. This can result in the patient being responsible for paying a larger portion of the bill or the entire cost of the service. Effective management of out-of-network denials involves understanding the reason for the denial, appealing the decision, and exploring alternative payment options to minimize the financial impact on the patient.

The “code first” note is your hint that two codes may be needed, along with sequencing direction. The “code first” note is an instructional note.

If you see “in diseases classified elsewhere” terminology you will assign two codes, with the manifestation code being sequenced after the underlying condition. The “in diseases classified elsewhere” (manifestation) code is actually part of the code title. The code with “in diseases classified elsewhere” documented can never be used as a principal diagnosis.

There can be confusion on how to report lateral- LT/RT and bilateral modifiers-50.

Coders report many of these incorrect or miss reporting altogether.

There is a false impression that medical coders sit in their pajamas all day while entering codes consisting of letters and numbers.

Here is what a coder’s job truly consists of!