Claim denials come in a variety of shapes and sizes, and it can be easy to point fingers when reimbursement doesn’t arrive as planned. As a result, some people have come to place the blame for denied claims solely on the shoulders of the medical coders, when in reality these are countless possible causes and culprits. According to the Advisory Board, there has been a 90% increase in claims deemed “uncollectable” between 2011 and 2017, but it’s unfair to say that it is all because of careless coding.
While it’s certainly true that some denied claims come from coders who accidentally code a condition that was never present to begin with, this is far from the most common issue. In fact, sometimes denials aren’t anybody’s fault at all; both parties can do what they think is the right thing only to realize that these methods don’t always match up. Take for example, Ahima’s example of severe dehydration due to acute renal failure. While a coder would code the condition with the renal failure as the primary diagnosis, misunderstanding on the payor’s end can result in a denial due to the severe dehydration not being listed as the primary. While this issue is covered in Coding Clinic advice, insurance companies often have problems finding skilled auditors to comb through their work and catch such mistakes. Worse still, sometimes payors don’t have updated coding guidelines when they first come out, meaning that they may be working on outdated information.
If you are a coder who must frequently confront denied claims, be sure to stick to your guns when you know you’re right. Others may be quick to put the blame on your end, but as long as you have justification for your code selections, you have a case for an appeal. The denial may very well be a simple miscommunication or misunderstanding, so it is always better to attempt a correction rather than simply taking the loss.