8 Common Reasons for Denied Claims in Ophthalmology Practices

By Michael Carroll on September 7, 2018

Denied claims have a significant impact on a provider’s cash flow. The good news is that 63% of denied claims are recoverable. However, even if your practice eventually collects the funds, you’re still losing money via the administrative costs associated with reworking the claim. In fact, one study found that it costs providers $118 per claim to work appeals. That’s an estimated $8.6 billion in administrative costs nationwide. What’s the best way to avoid those expenses? Avoid the following common reasons ophthalmology practices receive denied claims in the first place.

1. A modifier is missing or invalid. 

Modifiers are critical to the billing process. They allow billers to indicate that a service or procedure has been altered, but has not changed so much that it requires a different service or procedure code. For example, consider a patient that comes into the office for a follow up visit 24 to 72 hours after having cataract surgery. During the exam, the physician identifies a foreign body in the patient’s eye and removes it. That evaluation and management (E/M) service would be reported using a modifier 25. If the modifier is missing or one is not used at all, the carrier may deny a claim for that service.

2. An exam was in the global period, included in the major surgical procedure. 

The global period refers to pre-, intra- and post-operative care provided by the physician at no additional cost. For example, a minor procedure most likely has a 10-day global period. During that time, the physician should care for any issues related to the procedure without charge. However, it’s important for billers to know when the global period applies and what services are included. In the example above, the patient had a foreign body removed during a follow up visit. If the service of removing the foreign object is simply billed as an exam, it will most likely get denied because the carrier is expecting all exams during the global period to be at no additional charge. That’s why including the appropriate modifier is so important. Additionally, staff must use the appropriate code for a post-op follow up exam only during the global period. If the global period has expired a different code must be used, even if the patient returns for a reason related to the surgical procedure.

3. The diagnosis did not support the procedure.

Physician services are paid based on the fee associated with the CPT or HCPCS code submitted. The diagnosis code must support medical necessity. It tells the payer why the service or procedure needs to be performed. An incorrect code that does not support the procedure will result in a denial.

• Code to the highest level of specificity. The code should apply to the patient’s diagnosis, symptom, condition or complaint. If a diagnosis is not known, avoid using terms like “rule out” or “possible.” Instead, use a sign or symptom for identification.
• Code chronic conditions. According to Medical Economics, CMS and ICD-10 guidelines say, “Code a chronic condition as often as applicable to the patient’s treatment” and “Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment.” Every time the chronic condition is taken into consideration for treatment strategy, report it. Even if it is not treated at that time, still report it. However, if the chronic condition is not even considered, do not report it.

4. The care may be covered by another payer per coordination of benefits.

This denial usually comes when the carrier (in most cases Medicare) believes the patient has insurance coverage that is primary to the carrier to which your office has submitted that claim. Avoid this situation by improving your patient registration process and verifying coverage with each visit. If the patient believes the carrier is wrong, they will have to contact the Coordination of Benefits Contractor.

5. Patient was not eligible on the date of service.

Again, this denial is most often caused by a breach in the registration process. Verify the patient’s insurance card and eligibility at each visit. Even if their insurance card indicates they have coverage, eligibility should still be verified. The patient may have recently left their job. Or they may have been recently married, allowing them to switch carriers. Be proactive. Patients often forget to inform providers of these changes. To find the error, verify the patient’s name, gender, DOB, policy number and payer ID.

6. Invalid ID number, unable to identify insured.

ID numbers are just as important as social security numbers to insurance carriers. Carriers will not look for your patient under their name only. If an ID number is missing or invalid, the claim will get denied even if you have entered their name correctly. Avoid the situation in the first place by improving your registration process. For example, does your billing software prompt staff if the ID field is left blank? Does it automatically pull data for claims submission? Avoiding duplicate data entry will reduce the chance for human error. If staff are trained to verify eligibility before each visit, they must have the correct ID number at that time. If it is entered into your system correctly then, it will be correct when the claim is submitted. Have a process in place that allows for one data entry point.

7. Maximum benefits have been met.

Whether it’s a basic eye exam that is only covered once per year or a once-in-a-lifetime corneal pachymetry for glaucoma diagnosis, ophthalmologists must be proactive in determining if a patient has maxed out their benefits. For example, you may not know if pachymetry has been performed by another physician. To find out, you must get a signed advance beneficiary notice and submit it with a GA modifier.

8. Procedure is viewed as experimental.

Although provider agreements say the payor will not interfere with the professional judgment of the provider, often the recommended procedure is viewed as experimental. For example, some carriers still view corneal topography as experimental. Adding to the complication, different carriers have different opinions. Just because one views a procedure as valid, this doesn’t mean they all will. Staff must be trained to not only verify coverage, but also to verify benefits. What benefits are covered and what justification is required? Most states require payors to offer an external review process. However, the patient must initiate the review. It may be necessary for your staff to guide or provide additional information to the patient in this situation.

Denied claims have a significant effect on practices. AAFP says, “Poor management of the claims process can be detrimental to the financial health and sustainability of a practice, so avoiding claims denials should be the responsibility of everyone in the practice.” From schedulers to billers to providers, getting claims submitted correctly should be an all hands on deck mission.

Ophthalmology billing can be complicated and time consuming for your staff to handle in house. By teaming up with an outside medical billing company like Agnite Health LLC, an affiliate of Advantage Administration, Inc., your practice can turn your focus back on providing outstanding patient care – and leave the billing headaches to the experts. Our team has over 25 years of experience specifically with ophthalmology billing. We are ready to be held accountable for our services including timely charge posting, claim submission, claim rejections, denial management, patient and insurance A/R follow up, payment processing and posting, auditing and reporting. Contact us to start the discussion about outsourcing your medical billing.