• Become a Member of the Clean Claim Club in 4 Easy Steps

    Fourteen days is typically the time it takes for payers to process clean, no-error claims. Of course, the process is much longer when a claim is denied. How much additional time does your staff take to identify, research and correct a denied claim? Two days? Three days? Longer? 

    To help you prevent these lengthy turnarounds, here are four steps to ensure the cleanest of claims.

    1. Ask yourself, “Who’s the payer?”

    The first step in submitting clean claims is verifying the patient’s coverage:

    • Is the coverage current and active?
    • Does the plan require a referral?
    • Are you considered “in network”?
    • Is there a secondary or tertiary payer?
    • Does the patient’s name listed on the claim form exactly match the name on the insurance card?

    2. Determine the payer’s policies.

    There is no “one size fits all” when it comes to medical payers. Historically, Medicare Part B set a standard and other payers followed, but that is no longer the case. Each payer can and does have their own documentation and claim submission rules. Participate in payer listservs and verify information on payer websites. In time, you’ll recognize the unique variations for each payer.

    Medicare Part B:

    • Each Medicare administrative contractor provides local coverage determinations that detail how services should be billed and include acceptable diagnoses. Services are also impacted by CCI edits, which are updated quarterly. These edits state whether two services are bundled together and can’t be billed separately.

    Commercial Payers:

    • Billing policies and guidelines may or may not be posted on their website, and finding them can be like finding a needle in a haystack. You may need to contact customer service or your physician representative for assistance on certain services. Be sure to check for precertification or preauthorization prior to performing a service.  

    Remember that all policies are frequently updated. It’s best to check back often to make sure you have the most current information available.

    3. Append the correct modifier(s).

    Even though many ICD-10 codes include laterality or liderality. use of modifiers has not changed. To submit clean claims, you must know whether or not to append modifiers to your exams, tests and surgeries. Some modifiers are only appropriate for exams, while others are for tests and procedures. Be familiar with their definitions and how they are used.

    4. Use CPT to diagnosis code linkage.

    When billing for multiple services, make sure that the correct diagnosis is linked with the appropriate test or procedure. For example, if the patient has wet AMD in the right eye and dry AMD in the left, be sure to link the wet AMD with the injection.  

    Once you’ve dotted the I’s and crossed the T’s, your claim is ready for submission. Pay attention to your remittance advice so that you know you are being paid correctly. And if a practice error is discovered, communicate the costly error with your team so that it’s not perpetuated.

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    About the authors: Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding BulletinOphthalmic Coding Coach and Ophthalmic Coding series. Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She oversees the Academy’s Chart Auditing Service and is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series.