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

We are seeing an increased number of payor appeals which state “The HBV review performed is a payment integrity review, not a level of care or a medical necessity review, focused on the payment of services documented in the medical record. Facility documentation submitted and reviewed by HBV has identified outpatient services were delivered, and not acute care inpatient services. HBV is not denying the services provided, rather the review is focused on the payment of services documented in the medical record. In accordance with the application of MCG guidelines, HBV has determined that the services delivered are consistent with an outpatient or observation payment.” We have tried outlining the services performed, resources required, how IP level of care were met by the MCG / IQ criteria they outline. They are still being upheld. What else can we do to argue these denials?

Expert Q&A

We are seeing an increased number of payor appeals which state “The HBV review performed is a payment integrity review, not a level of care or a medical necessity review, focused on the payment of services documented in the medical record. Facility documentation submitted and reviewed by HBV has identified outpatient services were delivered, and not acute care inpatient services. HBV is not denying the services provided, rather the review is focused on the payment of services documented in the medical record. In accordance with the application of MCG guidelines, HBV has determined that the services delivered are consistent with an outpatient or observation payment.” We have tried outlining the services performed, resources required, how IP level of care were met by the MCG / IQ criteria they outline. They are still being upheld. What else can we do to argue these denials?

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?

Our organization gets late notification denials related to insurance information not being provided at time of admission. Our company makes an attempt to check coverage, but when unsuccessful, we receive the denial for no auth due to late notification. Our leadership wants these appealed and I struggle with an approach to write these appeals. I usually explain that we have no prior insurance information in our EMR, our facility has attempted to check coverage via Waystar or Relay, and that the member did not present insurance information. Is these any other suggestions/ ideas to use for these denials? Thank you.

Expert Q&A

Our organization gets late notification denials related to insurance information not being provided at time of admission. Our company makes an attempt to check coverage, but when unsuccessful, we receive the denial for no auth due to late notification. Our leadership wants these appealed and I struggle with an approach to write these appeals. I usually explain that we have no prior insurance information in our EMR, our facility has attempted to check coverage via Waystar or Relay, and that the member did not present insurance information. Is these any other suggestions/ ideas to use for these denials? Thank you.