Find-A-Code Focus Newsletter

Top 5 Reasons for Claim Denials

March 14, 2011

Wouldn't it be great to have a Top 5 claim denial list? One Medicare payer is doing just that. Every month they release the top 5 claim denial reasons. After reviewing several months and several states, a pattern emerges. Knowledge is power so let's review Alabama's Medicare Part B top 5 claim denial reasons for February 2011.

  1. NPI Missing for procedure code submitted. Services such as lab or x-ray require the NPI of the ordering provider. Consultations require the NPI of the referring physician.
  2. Diagnosis code invalid for date of service. This is why it is so important to stay current on your code sets. The cost of staying current is less than the administrative costs of claim resubmission.
  3. Paid amount greater than the allowed amount. “The claim was submitted as a Medicare Secondary Payer claim, and the primary paid amount for the line charge indicated was greater than the primary allowed amount”. Medicare Secondary Payer billing is also a top OIG Review item.
  4. Invalid claim frequency. In this case, original claims were not marked as 1 for electronic claim submission. Other electronic claim submission issues relating to various “loops” were also reported. These issues usually need to be resolved with the software used to submit your electronic claims.
  5. Paid and adjustment amounts do not equal claim charge on Medicare as secondary payer. Watch your fees and calculations.

These top 5 reasons seem to hold true for most states. Other states also had problems with:

  • Using NPIs that don't exist,
  • Using invalid Medicare ID numbers, and
  • Line item charges of zero (only PQRI codes can have zero for the charge).

Interestingly, most of these problems are clerical issues. The benefit of using clearinghouses for your claims submission is that they can catch many of these types of issues BEFORE they are submitted to Medicare. If you do not use a clearinghouse, we strongly recommend that you create your own “audit sheet”. Make a list of these common errors and then make it your policy to review claims for these common errors BEFORE submitting them.

Another specific area to address is understanding how to correctly bill Medicare as a Secondary Payer (MSP). Two of the top 5 reasons are related to this subject. To help address this problem, special guidelines have been issued by CMS. CLICK HERE to download the Medicare Secondary Payer Fact Sheet.

Implement policies in your office today to reduce claim denials. It will increase your bottom line - and quite possibly your blood pressure.


Source: InstaCode Institute


More Articles in March 2011



Which grouper would be more beneficial to you?

News Articles by Month
February 2020- 2
January 2020- 2
December 2019- 1
November 2019- 1
October 2019- 4
September 2019- 2
August 2019- 3
July 2019- 3
May 2019- 2
April 2019- 3
March 2019- 9
February 2019- 3
January 2019- 5
November 2018- 3
September 2018- 1
August 2018- 4
June 2018- 5
May 2018- 4
April 2018- 1
March 2018- 1
February 2018- 8
January 2018- 6
2017 - View
2016 - View
2015 - View
2014 - View
2013 - View
2012 - View
2011 - View
2010 - View
2009 - View
2008 - View
free demo
request yours today
for any budget
sign IN
welcome back!