Why E/M Services Claims Get Denial?

According to data from the Centers for Medicare & Medicaid Services (CMS), roughly 15% of evaluation and management (E/M) services don’t get paid correctly, making up about 9.3% of all improper payments in Medicare’s fee-for-service program. The common reasons for claims being denied include situations where multiple providers in the same group offer similar services, incorrect coding for the Correct Coding Initiative (CCI) bundling, submitting the same claim more than once, and billing inaccuracies for global surgery. To address these claim denials and reduce the frequency of denials for E/M services, it’s essential to understand these issues and their resolutions.

Common E/M services Claim Denials

1. Similar Services

Having ‘similar services from multiple providers in the same group’ is a significant reason for denied claims. This means you received a denial because you received reimbursement for almost the same service within a certain time. When you receive this denial, first check if it’s not due to a previous payment.

To avoid having your claims denied, keep these billing tips in mind:

• If doctors work together in a group and have the same specialty, they should bill and receive the reimbursement as if they were one doctor.
• If multiple doctors with the same specialty in the same group see the same patient on the same day, only one doctor can bill for their services, unless the patient’s issues are unrelated.
• Doctors in the same group but with different specialties or subspecialties can bill and get paid regardless of their group membership.
• Conduct regular medical billing audits of your practice and medical billing to spot anomalies and take the initiative to resolve them. For healthcare audits, you can find some spare time and do it by yourself or get it done by medical billing audit services. The best advice is to outsource it to the professionals in this field. 

If you want to challenge a claim, make sure to give medical papers that show why the services were needed on that day. When you appeal, it can be useful to mention the specialty of the doctors if more than one doctor in the same group billed for services to the same patient on the same day. This can help explain why multiple doctors were necessary.

Wrong Codes Cause Payment Problems

Sometimes, clinics make coding errors that lead to their claims being rejected. The Centers for Medicare and Medicaid Services (CMS) created the Correct Coding Initiative (CCI) to help clinics use the right codes, preventing payment mistakes. CCI edits are designed to stop incorrect payments caused by the wrong code combinations. You can review these edits on the CMS website before sending your claim. They update them every three months. It’s a good idea to double-check your documentation and the codes you use, especially for E/M services, through internal audits.

Submitting the Same Claim Twice

Submitting the duplicate is the most common error among healthcare providers, primary care clinics, and big healthcare organizations as well. 

If you send in two claims for one thing to your insurance, they’ll tell you it’s a Duplicate Claim. This happens when you want or unwantedly receive reimbursement for the same service.

To prevent this, you should first check your claim’s status to make sure it’s not a mistake from a previous payment. Usually, if you have more than one service from the same doctor on the same day, you should group them together as one claim.                                                                                        

Global Surgery Denials

CMS decides how many days are covered for surgery. The details for each surgery code can be found on the Medicare Physician Fee Schedule database (MPFSDB). Be sure to look up any surgery code that could lead to your claim being rejected on the website. You can find the ‘global day’ information on the physician fee schedule, which tells you about the coverage period.

For instance, if it says the global days are 90, it means the cost covers a major surgery along with one day before the surgery and 90 days after it.

                                                                                          

Remember, when you get medical services (E/M), they might have specific rules during a certain time frame. To make sure you get paid for these services, check how long it’s been since the operation and provide the right diagnosis info.

To avoid your medical claims being rejected, the CMS suggests a few things. First, aside from following the rules for billing a specific E/M code, think about if the service is necessary. For example, it’s not reasonable to give a high-level service for a common cold.

Another thing to do is think about different factors when choosing the right codes for E/M services. Consider the patient type, where the service happens, and how complex it is. Lastly, make sure to get the required signatures from the doctor or other healthcare providers.

Conclusion

Around 15% of evaluation and management (E/M) services get wrongly paid, causing nearly 9.3% of Medicare fee-for-service payments to be incorrect. Common reasons for claim denial include “similar services from multiple providers in the same group,” “inaccurate CCI bundling,” “duplicate claim submission,” and “inaccurate billing for global surgery.” To avoid these denials, firstly, ensure that doctors in the same group practice the same way.