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Young Ophthalmologists
Claim Submission: Getting It Right the First Time
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For those of you who process explanation of benefits (EOBs), what is more frustrating and time-consuming than to have a claim denied, which then requires reprocessing?

undefined The truth is, there are mistakes common to all practices that, if avoided, can lead to membership in the “clean claim club.”

Identifying the Error
The Center for Medicare and Medicaid Services (CMS) has published a list of common mistakes.
  • Not keeping up-to-date with new guidelines implemented by your local Medicare contractor. Each Medicare payer has a listserv that e-mails coverage updates directly to you on a weekly basis. There is no charge for this service. Simply visit the payer Web site and sign up.
Local coverage determinations (LCDs) are the rules and regulations by which you will be held accountable for in an audit. They also contain a list of diagnosis codes deemed medically indicated.

Assign at least one person to be responsible for receiving the e-mail updates and communicating the new data to everyone in the office. Remember, once the policies have been posted on the Web, the payer has met their obligation to inform you. For a list of payer sites, visit
  • Not completely reading, understanding or applying the appropriate resolutions regarding remittance advice messages. Unfortunately, the explanations may be difficult to decipher. For example, if the diagnosis code is not payable with a particular test performed, the EOB may state that the test was not medically indicated. For a list of remittance advice messages, visit
  • Continuously re-filing the same claim in hopes that, one day, it will get paid. I once audited a practice where each IOL measurement (CPT code 76519) was denied because no national provider identifier (“NPI”) was listed in the “referring physician” box of the CMS 1500 form. The claims had been resubmitted every other month without correcting the error.
  • Not using modifiers when they are necessary.
  • Hard-coding modifiers into software programs so that they are always used, such as modifiers 25 and 59.

Communicating the Error to the Team
Those who mark the charge sheet may not routinely communicate with those entering charges, who may not communicate with those who process the claims. Hence, the same mistakes are made over and over again. Those who process the EOBs should routinely educate all others in the team on the errors they are finding in claims processing.

Implementing Corrective Action
Why is managing denials so important? It reduces claim-submission errors, reduces administrative costs and, of course, increases reimbursement. How long does it take your practice to identify and resolve a denied claim? Are there sufficient staff members to do the work?

A Fast Fix
The first step in managing denials is to acknowledge the fact that unnecessary denials impact your practice in various ways, as outlined earlier. Make working the denials a priority. Track what action has been taken and follow-up if payment has not been received within 30 days.

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About the author: This article was written by AAOE coding executive Sue Vicchrilli, COT, OCS. It originally appeared in the August 2009 Coding Bulletin.

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