Expert Q&A

Should we recode CPT codes and rebill claims that were incorrectly coded and then denied?

March 27, 2025 · Anna McGraw

If the payer permits that and it is within timeframe, rebilling with the correct codes is recommended.

Answered by: Karla Hiravi, BSN, RN Vice President Clinical Resources, AHDAM and PayerWatch

Related

I have been working on appeals at my facility and have come across this frequently: Payers deny diagnoses based on their own clinical criteria, saying the documentation doesn’t meet their definition. AHA Coding Clinic 4Q 2016 (pp. 147–149) mentions that payers may require specific criteria to establish a diagnosis. Has anyone successfully challenged this or asked Coding Clinic for clarification?

Expert Q&A

I have been working on appeals at my facility and have come across this frequently: Payers deny diagnoses based on their own clinical criteria, saying the documentation doesn’t meet their definition. AHA Coding Clinic 4Q 2016 (pp. 147–149) mentions that payers may require specific criteria to establish a diagnosis. Has anyone successfully challenged this or asked Coding Clinic for clarification?

Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?

Expert Q&A

Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?

A Medicare Advantage organization is requiring certain criteria to be met that is more than what Medicare guidelines require. I don’t understand why they continue to deny after a first level appeal has been done that explains we don’t need to adhere to their requirements that are above and beyond what traditional Medicare requires. Can you help?

Expert Q&A

A Medicare Advantage organization is requiring certain criteria to be met that is more than what Medicare guidelines require. I don’t understand why they continue to deny after a first level appeal has been done that explains we don’t need to adhere to their requirements that are above and beyond what traditional Medicare requires. Can you help?