Linking Medical Insurance Codes - Stop Losing Money on "Related" Insurance Claims

What is “binding”? This is when an insurance carrier combines two or more CPT codes, replacing one comprehensive code, often ignoring modifiers along the way. This practice can reduce your receivables. When the codes are combined, the codes are grouped together, and the insurance carrier only allows payment on a schedule for one code, which, in their opinion, is appropriate.

There are ways to get around a bunch. First you need to make sure that you make the right claim in the original submission. For example, if you pay an E & M code for a patient who comes with high blood pressure, but the patient also complains of knee pain, and you end up doing aspiration of the knee joint, then you need to make sure that you use the right modifiers to indicate what you are doing. You want to pay the E & M code, say, this is 99213, with a modifier of 25, to indicate that this is a separate and excellent service provided during the same visit. Then you must pay for the knee joint aspiration with the appropriate code using the 59 modifier to indicate a separate procedural service.

It is very necessary to know the proper use of all the different modifiers in order to get a full refund for your services. Also important is the ability to correctly read EOB (explanation of the benefit statement). EOBs can be quite complex, and it is important to understand what the insurance company did with the claim.

When a claim is processed and you receive an EOB, you need to make sure that the insurance company resolved both codes separately. In the end, you made a visit to the office to cope with high blood pressure, and you made an aspiration that was completely separated from the office visit.

If the insurance agent links your codes, you must file an appeal. In many cases, the insurance carrier processes the claim and divides the codes if you go through the appeals process.

The appeal does not have to be difficult. This could be a letter form that you develop where you just need to fill in the blanks. Many carriers associate claims with initial processing, since most branches will not appeal the claim. Just think how much money they will save!

You may think that it is not worth spending time on the appeal, but you may be surprised if you know how much money you have actually lost over time. If you have a system for filing appeals, which are a fairly simple process, it will not take long and you can increase your receivables. In my opinion, it is worth the effort.

Copyright 2007 - Michel Redmond