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Orthopedic Coding Alert

Take 4 Steps to Appeals Success in 2006

We boil the appeals changes down for you Now that you-ve gotten the basics about Medicare's new appeals process, we-ve highlighted the facts you need to know. Check out the following four steps that can get your appeals strategy right on the money. 1. Understand Reopening After your carrier has made an initial determination, the claim can be reopened to correct minor errors, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J. Reopening serves as an informal first step in the appeal process and has been a -long-standing source of confusion.-

Why: Usually carriers reopen a claim for minor problems, such as a missing modifier, incorrect patient information, or a missing UPIN for the referring physician, Cobuzzi says. You will usually reopen a claim over the phone, she says.

Remember: If your carrier agrees to reopen a claim, you need to make the specified changes--but this does not constitute an appeal for carrier review. The errors each carrier accepts for reopening will vary, but CMS requires that carriers provide a reopening process. So if your carrier refuses, refer them to this new CMS guideline.

Example: Suppose you file a claim for an injection (20600, Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]) and a level-three established patient E/M service (99213) on the same day, but you fail to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213. You-ll receive a denial during the initial determination phase. You can call and reopen the claim, add modifier 25, and hope the carrier will pay your claim via the reopening process. 2. Know the Basics of Redetermination CMS formerly referred to the first level of the appeal process as -post payment review- or -carrier review,- but in 2006 this level will be known as -redetermination,- says Steven Verno, NREMTP, CMBSI, director of reimbursement for Emergency Medicine Specialists in Hollywood, Fla.

Redetermination -is the only level that includes the carrier that initially denied or underpaid the claim--all other levels include independent review,- Cobuzzi says.

Time frame: You must file a request for redetermination within 120 days of the initial denial or underpayment (receipt of the Explanation of Benefits), Verno says. The 120-day time frame has been in effect since July 31, 2002, per the Benefits Improvement and Protection Act.

Form: Use form CMS-20027 for all redetermination requests. You can find all necessary CMS appeal forms online at

Action: There is no minimum dollar amount [...]

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