Reasons For Medical Billing Reversals

Reasons For Medical Billing Reversals

Reversals can happen for a myriad of legitimate and not so legitimate reasons. In a recent study, the top reasons for medical billing reversals are as follows:

1- Incorrect payable diagnoses codes, the biggest offenders in this category were:
Modifier 59 – distinct procedural service
Modifier 76 – repeat procedure by same physician
Modifier 24 – unrelated evaluation and management service by same physician during postoperative period
Modifier 25 – significant separately identifiable evaluation and management service by same physician on the day of a procedure.

2-Provider Billing Errors – As long as medical billing is coded by humans, there will be errors, that’s just a fact and provider errors were the number two cause of reversed billing. The different types of billing were:
Correct quantity billed – often times the amount of services rendered is miscalculated;
Correct procedure code – this one can be difficult, that is why outsourcing your medical billing to a partner is a great idea;
Correct billed amount – another big issue, incorrect pricing will get your medical billing claims rejected.

3-Medical Review – The biggest reason for reversals of payment was lack of documentation to support medical necessity for the following procedures ambulance service;
frequency of bone mass measurement;
to support medical necessity of critical care same day.

Outsourcing your medical billing will help alieviate these reversals as your medical billing partner is well versed in not only keeping up with the coding changes that happen throughout the year, but will also double check your medical billing claims before submission for proper documentation. These checks and balances will insure that your claims will be handled in a timely manner and properly reimbursed without the amount of reversals you may have been experiencing.

View all Articles by: Melissa Clark, CCS-P