The most common reasons a claim may be denied:
It is strongly recommended that provider practices perform causal analysis of claims being denied and update their workflows to ensure the practice is not fragmenting claims, and also submit claim(s) correctly the first time. This will save your practice time and money.
Submitting unnecessary documentation is unacceptable; therefore, be sure to review your documentation and provide diagnosis codes to substantiate your appeal; otherwise, your appeal will deny costing you more time and money for the next level of appeal.
Use the LVAM protocol when submitting multiple (25 or more) reopenings and mail in the forms. These will be reprocessed with an automation process that will save time and money for both the provider and National Government Services.
- Part B Reopening Request Form
- Large Various Adjustment Macro (LVAM)
- YouTube Video: Holistic Approach to Avoiding Administrative Burden
Duplicate claim:
- Service was performed multiple times on the same day, but submitted on separate claims or separate line items, and did not include appropriate modifiers 76 or 77.
Medical necessity for policy related topics:
- Local Coverage Determinations
- Podiatry L33636 and A57759
- Physical Therapy L33631 and A56556
Medically unlikely edits and correct coding initiatives:
Modifier KX for use with physical therapy:
- KX Modifier Threshold
- KX appropriate when patient qualifies above the threshold under the exception regulations. These should not be reopenings. Providers are required to pre-calculate up to the therapy cap and submit claims with the KX modifier.