March 11, 2024

Glenwood's Strategy for Successful Denial Resolution

Are your medical claims getting denied?

Happens to the best of us. One common hiccup is using those unspecified ICD-10 codes.

The ICD-10 coding game is a big deal, consisting of 68,000 codes, with new ones added each year — 230 new CPT codes added in 2024. It's a bit of a code shuffle too, with ICD-10 swapping out some vague codes from the old ICD-9 days for more specific ones.

Moreover, big players like Medicare, UHC, Aetna, Cigna, Emblem Health, and Tufts have established specific coding edits to cover specialty-based operations. And to keep us on our toes, they keep changing the rules, making life a bit tricky for healthcare providers.

So, how do you navigate this convoluted maze?

The key is to be precise with your medical codes and avoid vague, unspecified ones.

At Glenwood, we prioritize a streamlined approach to claim processing, enabling healthcare professionals to devote more time to patient care while alleviating concerns regarding coding compliance and reimbursements.

Expert Denial Resolution Strategy: Glenwood's Approach

Medical codes are always in a state of flux. It's a dynamic world with frequent additions and deletions every year, whether it's CPT codes, diagnosis codes, or HCPCS codes.

At Glenwood, we stay at the forefront of industry changes by consistently updating our program. We implement validation fixes tailored to the updated insurance policies and in response to the initial denial, ensuring private practices effortlessly adhere to the most recent regulations without unnecessary stress.

Moreover, we verify that all denied claims are meticulously resubmitted after rectifying errors, effectively sealing revenue leaks.

Let's dive into some real-life scenarios to see how we tackled denials.

Scenario 1: One of our providers faced a denial for the CPT code 93306, which involves a duplex scan of extracranial arteries, specifically a complete bilateral study. The initial diagnosis code supplied by the provider's office was I77.9 (Disorder of arteries and arterioles, unspecified).

Our team took immediate action and thoroughly assessed the claim denial. After scouring the patient's medical record, we detected a crucial inconsistency and swiftly rectified the diagnostic code to I25.10, indicating atherosclerotic heart disease of the native coronary artery without angina pectoris.

Scenario 2: In another instance, a provider encountered a denial for the CPT code 93314–26 related to transesophageal echocardiography with real-time image documentation. The hiccup occurred when the provider's office first submitted the claim with the diagnosis code I48.92 (unspecified atrial flutter).

Our team swiftly addressed this issue by resubmitting the denied claim following established guidelines and incorporating the primary diagnosis code R07.2 (Precordial pain).

Scenario 3: In yet another situation, a provider encountered a denial for the CPT code G2066 related to interrogation device evaluation for implantable cardiovascular monitors. The initial denial cited diagnosis codes Z95.810 (Presence of automatic — implantable — cardiac defibrillator), I50.21 (Acute systolic — congestive — heart failure), and I42.9(Cardiomyopathy, unspecified).

We recognized the error and promptly resubmitted the claim with the diagnosis code Z86.73 (Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits), ensuring alignment with accurate coding practices.

Our team systematically addresses every denial by conducting a comprehensive assessment of the information provided by the physicians. Additionally, we strictly adhere to the ICD-10 coding guidelines and meticulously follow specific coding edits established by insurance companies.

The outcome? Seamless claims processing, which is free from denials and cash flow hurdles. This strategic approach enabled us to resolve a denial situation valued at $75K, securing a payment of $69K. Moreover, our proactive measures effectively prevented further claims denials, sealing unnecessary revenue leaks.

Glenwood software and processes (GlaceRCM and GlaceEMR) provide a 95% first-pass acceptance rate, strive for a 96% claims payment within 30 days, and aim for a 99% collection rate for payer claims. This unwavering commitment guarantees that your practice experiences a more seamless revenue stream, elevated collections, and increased profitability.

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