Imagine if you received a claim denial message from an insurance payer and it states:
“THIS SERVICE IS NOT PAID. THE SUBMITTED DIAGNOSIS CODE IS NOT SPECIFIC ENOUGH FOR THE ACCURATE DETERMINATION OF BENEFIT ELIGIBILITY.”
What would you do?
We will tell you why chiropractic practices are getting these claim bill line denials and what can you do to handle such claim denials. These claim denials are based on ICD-10 Official Guidelines for Coding and Reporting pertaining to Excludes 1 notes. The official updates to ICD-10 chiropractic codes for the Fiscal Year 2022 went into effect on October 1st, 2021, but Excludes 1 notes were around since the beginning of the implementation of ICD-10-CM.
What are Excludes Notes?
The ICD-10 codes for chiropractors have two types of Excludes Notes – Excludes 1 and Excludes 2. Each type of note has a different definition but is somewhat similar. Here is how.
Excludes 1
A type 1 Excludes note means “NOT CODED HERE!” This means the code excluded should never be used at the same time as the code above the Excludes1 note. It is usually used when two conditions cannot occur together.
Excludes 2
A type 2 Excludes note means “Not included here”. This means that the condition excluded is not part of the condition represented by the code, but in this case, the patient may have both conditions at the same time.
Example:
G44 Other headache syndromes
Excludes 1:
headache NOS (R51)
Excludes 2:
Atypical facial pain (G50.1)
Headache due to lumbar puncture (G97.1)
Migraines (G43.-)
Trigeminal neuralgia (G50.0)
Claims Denials – How to Avoid Them
Claim denials can be classified into two main categories: hard denials and soft denials. Hard denials are irreversible and lead to lost or written-off revenue, while soft denials are temporary and offer the potential for payment upon claim correction or submission of additional information.
The 2013 American Medical Association National Health Insurer Report Card highlights the top five reasons for medical billing denials:
a. Missing Information: Even a single required field left blank on a claim form can trigger a denial. Demographic and technical errors, such as missing modifiers, incorrect chiropractic diagnosis codes or CPT codes as per the plan, or the absence of a Social Security number, account for 61% of initial medical billing denials and contribute to 42% of denial write-offs.
b. Duplicate Claim or Service: Duplicates, which occur when claims are resubmitted for the same encounter on the same date by the same provider for the same beneficiary and service item, are a significant factor in Medicare Part B claim denials, reaching up to 32%.
c. Service Already Adjudicated: This error arises when benefits for a particular service are already included in the payment or allowance for another service or procedure that has already been adjudicated.
d. Not Covered by Payer: Claim denials for procedures not covered under patients’ current benefit plans can be avoided by verifying details in the insurance eligibility response or contacting the insurer before administering services.
e. Time limit for filing expired: Many payers impose a specific timeframe within which medical claims must be submitted, encompassing both the duration for reworking rejections, whether automated through system edits to identify coding errors or other inaccuracies, and complex reviews conducted by licensed medical professionals to assess service coverage and necessity. In the fourth quarter of 2015, 81% of complex claim denials were attributed to inpatient medical coding errors, which can lead to delays surpassing the medical billing deadline. To mitigate such occurrences, it is crucial to implement workflow practices that promptly alert staff when medical claims approach the filing limit.
f. Coordination of benefits: If patients are covered by multiple insurance plans, claims can face delays or even denials if their coordination of benefits is not current and accurate.
g. Not using ICD-10 codes for chiropractic to the highest level of specificity: Claim denials occur as a result of chiropractic diagnostic codes (ICD-10) that do not use the highest level of specificity. That’s why it’s important to ensure a high level of accuracy and compliance with the most current and appropriate chiropractic coding and billing practices and guidelines. Choosing inaccurate ICD-10 codes for chiropractic could result in claim denials, which puts a strain on the financial process of your practice. Knowing when to use common ICD-10 codes for chiropractors and some basic strategies for resolving claims denials can save you time and improve insurance reimbursements. Here is how to effectively handle claim denials:
1. Understanding the Current State of Your Denials
Before you appeal for a denied claim, you should first ascertain why the claims were denied by a payer. Below is a list of the most frequent denial reasons that chiropractic clinics experience:
• Chiropractic ICD-10 codes in the HCFA form don’t include the highest appropriate level of specificity.
• When coding diagnosis codes for chiropractic services, your biller has not considered Excludes1 and Excludes2 notes.
•
Services not covered/coverage terminated
•
Referral or prior authorization required
• Lack of proper documentation to support medical necessity
• Duplicate billing
•
Upcoding or unbundling
• Missing modifiers on chiropractic claims
• Chiropractic diagnosis codes not matching the procedures provided
[Also read: ICD-10 Chiropractic Codes: The Application of A, D, and S Extensions]
2. Review your EOBs carefully
Reviewing EOBs is one of the most important steps in effective claims processing. When you receive remittance advice, an explanation of benefits (EOB) from a payer, review it carefully. EOBs would clearly indicate whether your claim was paid in full, partially paid, or denied. If the claim was denied, check the denial reason(s) and read the specific chiropractic diagnosis codes, procedure codes, and documentation required (if mentioned).
3. Ensure 100% accurate patient information and codes
Inaccurate patient information and chiropractic diagnosis codes are the most common reasons for claim denials. Check the patient file and ensure that you’ve up-to-date information about the patient’s insurance, contact details, and other information. Also, check if the provider has selected the correct ICD-10 diagnosis codes for chiropractic services, specific to the patient’s condition(s). If the patient has multiple conditions and you find suitable chiropractic ICD-10 codes, take time to study the payer policy under the chiropractic diagnostic codes and select the most relevant ones with the highest level of specificity.
4. File an appeal within a week
If your claim got denied because of Excludes 1, Excludes 2, or other reasons mentioned above, you may appeal the decision as per the payer’s guidelines. The most crucial step of a successful denial management process is the ability to resubmit an appeal within a week. The appeal should include an explanation of your reconsideration request, supporting documentation if required, a correct HCFA form with proper CPT and diagnosis codes for chiropractic services, a copy of the denied claim in question, and copies of earlier communication with the payer regarding the denied claim.
5. Monitor your appealed claim
After you have submitted the claims, keep track of the progress. Track the status of the appealed claim. Once you’ve received your reimbursement for the appealed claim, it will help you identify the solution for a denied claim and prevent you from repeating the same coding mistakes moving forward. Besides, you can use this knowledge when you send appeals in the future.
Outsource Your Billing and Denial Management Process
Handling claim denials can be frustrating and time-consuming. You can effectively handle your billing process and claim denials by outsourcing your chiropractic billing to zHealth’s Managed Billing Experts. That way you won’t waste time trying to figure out what to do each time, and the denial will get handled promptly by billing specialists.
zHealth offers managed billing services for chiropractic practices. We specialize in chiropractic revenue cycle management, chiropractic diagnosis codes reviewing, ERA/EOB posting, denial management, and AR follow-up at cost-effective rates. To know more about our denial management and billing services, contact us at [email protected] or +1 (800) 939-0319.
Wrapping Up
Most chiropractors have a list of the common chiropractic ICD-10 codes that they use often in their practice. Using chiropractic software makes it easier to use the common chiropractic ICD-10 codes based on the patient’s condition. For instance, zHealth chiropractic software allows you to create favorite lists of ICD-10 for chiropractors. This way you can use the specific favorite list based on the patient’s condition or insurance company.
Always stay updated when it comes to ICD-10 codes for chiropractors as changes are introduced every year by CDC’s National Center for Health Statistics. Keep checking the rules for ICD-10 codes for chiropractic services. Choosing the right ICD-10 chiropractic codes when creating patient invoices and submitting your claims will save you tons of time and money. Outsourcing your chiropractic billing process can help you increase your reimbursements and maximize your profitability – quickly, and easily.
[Also read: In-House Chiropractic Billing or Outsource It – That’s a Million Dollar Question!]
