1. Coding Denials: 7 Strategies
for Maximizing Cash
By Chris Klitgaard, CEO
with Kimberly Vegter, CPC, CPC-I, AAPC Certified ICD-10 Trainer

2. 1
There are really only a handful of possible
outcomes when a claim is being processed.
It may be paid correctly, be paid incorrectly or go unpaid.
And, of course, it may be denied altogether.
Denied. Let’s face it. There are many reasons a claim might be
denied. No coder or coding department is exempt from having
claims denied. It happens to the best of the best and to the rest.
So the true question is, given that the average claim denial
costs $251
, how can we minimize the loss that results from
coding claim denials? In fact, nearly 30% of total filed claims
are denied due to minor errors in coding and technical aspects2
.
That doesn’t take into account the many more that are denied
due to registration or billing issues.
Code It Right the First Time
The most obvious way to keep denied claims below the MGMA
benchmark of 4% is to send out a “clean claim” the first time,
and that entails more than just attention to detail3
. It requires
making sure the right people with the right training are in the right
positions. Coders should have focused training not only in coding,
but also in the particular specialty in which they are coding. The
coding discipline is both comprehensive and layered, so while all
coders must comply with the same set of general guidelines, each
specialty also has its own set of rules.
To complicate matters further, each payer has its unique claims
submission requirements as well as its own proprietary medical
policies. It’s very difficult to understand—and apply—every rule for
every payer. Just thinking about it can be maddening. Here’s an
alternative: understand the provisions for your organization’s top
five payers and remember Medicare sets the standard.
Rules and policies aside, communication among departments
within an organization can also affect the volume and frequency
of coding-related denials. Coders speak a language different
from their colleagues in patient accounting and claims processing
departments. Yet, when they understand the interdependence of
their roles as well as their intrinsic value to revenue cycle as a whole,
working toward the same goal—payment of claims—becomes
clear. When departments communicate clearly and regularly, claims
are submitted correctly and paid more quickly, more often.
Try Triage as a
Methodology
Sounds serious, doesn’t it?
The term triage is defined as
“the assignment of degrees
of urgency to wounds or
illnesses to decide the
order of treatment of a
large number of patients.”
Typically, triage is used in
reference to patient care
but it’s just as important
to the revenue cycle,
especially when there is
backlog of denials.
When a systemic problem
with denials exists, try
triage. Identify the barriers
to claims processing and prioritize those areas. For instance, if
several claims are held or denied for registration issues such as
incorrect ID, eligibility, coverage termination or group number, then
training is needed for the staff responsible for intake. If claims are
rejected for modifier usage, specificity or sequencing, then training
is needed for your coding department. Denials also occur for
failure to pre-certify or preauthorize, fee schedule issues, duplicate
claims and so on. These are general billing issues that are handled
by your patient accounting office.
Clearly, there are many ways to go wrong. Identifying areas
of concern and addressing them with training and education
will minimize denials that would otherwise slow down your
revenue stream.
TRAINING TIP
Everyone from intake to collections
plays a role in creating a “clean claim.”
TRAINING
TIP
Not everyone
processes
information in
the same way.
Incorporating a
variety of learning
styles into your
coding training
model can prevent
a coder from being
left behind.

3. 2
a problem does arise. Big picture aside, painstaking attention
to detail is a desirable trait among coders. Why? Because
transposing a number when entering a date-of-birth or insurance
ID causes claim rejection just as easily as using the wrong
modifier or ICD-9 code.
Precertification is another small step in a larger process that
can have a detrimental effect on your A/R. Most managed care
organizations necessitate approval for certain procedures and
admissions; without it, payment will be denied. Be sure you have
a process in place so that neither precertifications for admissions
nor prior authorizations for procedures fall through the cracks.
All That Said, Expect Denials
There are some denials that are destined to occur no matter how
diligent you are in submitting clean claims. Without question, the
most dreaded denial is “not medically necessary.”
Stay on top of these denials by taking steps to appeal them as they
occur. First and foremost, make sure the claim is indeed medically
necessary. This may require some research on the part of your
coding staff or even a query to the provider. Once you have verified
that the coding is correct, the documentation is adequate and the
medical decision-making is appropriate, proceed with filing the
appeal. Supply the appropriate medical records and, if necessary,
include articles, images or even a letter from the provider to
support the reason for the service.
Another common source of denials occurs when providers submit
claims directly via their electronic medical record (EMR), thinking
that their claims are being submitted accurately. In truth, that’s
often not the case, but these occurrences can be minimized by
having a strong audit protocol in place. When coders and providers
work together, a clean claim is more likely. Further, educating
providers on documentation practices can enhance best-practice
coding methods.
Train, Train, Train
Educating the coding team is a never-ending process, as the
discipline is constantly changing. Failure to keep up will result
in paying for these deficits in more ways than one: reduction of
revenue, penalties for noncompliance, pre-payment audits and
post-payment audits.
And that’s why credentialed coders are critical to every
team, regardless of size and scope. Coders actually reduce an
organization’s risk because they understand coding conventions
in various code sets and because they are required to take
continuing education credits annually to maintain their credentials.
One survey indicated that only half of the medical billers and coders
are certified; however, considering the increasing competition and
coding regulations, certification is expected to become a necessity
by 2020 with employers expecting applicants with certifications
before hiring.4
Among many coding credentialing entities, the American Academy
of Professional Coders (AAPC) and the American Health Information
Management Association (AHIMA) are nationally recognized and
considered the standard for coding.
While certification and continuing education are vital to keep up
with edits, regulations and changes in payer policies, it is also
essential to have specialty-specific training. Staying current with
the changes unique to a specialty will help maintain the efficiency
of the revenue cycle.
Stop Making Silly Mistakes
Denials received from payers are inevitable. To minimize avoidable
denials and improve turnaround time, focus on decreasing the
number of “little” mistakes, as they have far-reaching effects.
Again, making sure you have well-trained staff who see the big
picture—the role of coding in the revenue cycle—is paramount.
Coders must understand the importance of entering patient data
correctly into the system and know how to trouble-shoot when
OF PROVIDERS
DON’T HIRE
CERTIFIED CODERS5
OF CODERS ARE
EXPECTED TO CODE
OUTSIDE THEIR
SPECIALTIES6
26%
31%
TRAINING TIP
There are three main types of adult
learning styles: visual (seeing), auditory
(hearing) and kinesthetic (touching).
Incorporating all three into your
training model for coders is optimal.

4. 3
Not allowing a coding denials backlog to build is definitely best
practice, yet many coders find themselves struggling with too
many denials—or simply too much coding work in general—and
too little time.
Attack Backlog—NOW!
What if you are way behind? If you are drowning in coding-related
denials, you have multiple options: lighter fluid and a match,
prioritizing your work or asking for help.
While most coders would be more than happy to eliminate their
denials via fire, this approach is actually not recommended.
Acknowledging the awfulness of working coding denials, though,
is the first step in making them manageable.
It’s common practice among coders to address denials last—
after coding and submitting charges, after answering emails and
phone calls, and after every other assigned task, including a walk
down the hall or around the block for an afternoon latte. Working
coding denials is just plain undesirable. But, it’s still important to
the revenue cycle because it quickly brings in revenue that would
otherwise be lost. Paying attention to corrected claim timeframes,
appeals deadlines and timely filing limits keeps denials moving
toward the overall goal: payment.
Try these tactics to force coding denials work back to the top of
the to-do list:
• Block out time daily to work backlogs.
• Break down the sheer volume of coding denials into manageable
chunks to make the task more palatable and attainable.
• Measure results at the bottom line. If you track the payments
received as a result of coding denials worked, you’ll find
validation in making this tough task a priority.
Knowing when to ask for help is also critical. If daily prioritization
of coding denials isn’t enough, consider a proven coding partner
to manage this aspect of your revenue cycle.
Share the Workload
According to a 2014 report in LinkedIn Pulse, “more providers will
outsource their billing in 2015 than ever before.” (Harold Gibson, 2014)
More and more providers are looking for proven partners to serve
as extensions of all or a portion of their revenue cycle operations,
and coding is no exception. Knowing when and why to consider
an external partner is important, because even if one is not the
right fit for your organization today, it may be in the future.
An honest look at the sheer volume of coding work is a good
place to start, and backlogs are a primary indicator. Also,
consider whether there have been significant staffing changes,
or if coding is generally understaffed. Finally, pay attention to
increases in the number of providers, both sudden and gradual.
If growth in coding has not mirrored growth in providers, coding
will inevitably fall behind.
0%
Strongly
Agree
11%
Agree
47%
Disagree
37%
Strongly
Disagree
5%
10%
20%
30%
40%
50%
7804 RESPONDENTS
Physician(s) in my office have a solid
knowledge of coding and compliance rules.7
91%
82%
WHILE ONLY
of coders said accuracy
of coders said productivity
When asked about the prime directive
of the manager8
:

5. 4
© 2015 MEDIREVV, INC.
Conclusion: Start Today!
Having a tried-and-true process in place for managing denials
will affect a provider’s bottom line. How? Clean claims get paid
faster. Improvements to internal workflows and commitments to
staff training both result in increased productivity, which reduces
costs. Distinguishing between avoidable and unavoidable denials,
and having a systematic workflow for each saves time, and time
is money. And, last but not least, finding a proven revenue cycle
partner experienced in coding may be the silver bullet to clearing
the backlog and paving the way to restoring and maintaining
revenue cycle health.
Chris Klitgaard is CEO of MediRevv, a Coralville, Iowa-based
healthcare revenue cycle management company specializing in
helping hospitals, health systems, academic medical centers and
physician groups improve their cash flow and grow their revenue.
Kimberly Vegter is Coding Educator at MediRevv. Kim’s medical
billing and coding experience spans 20 years as a coder, educator,
and consultant. She helps providers keep up with healthcare
reform and effectively manage patients without sacrificing
standards of care.
While there are many outsourcing options from which providers
can choose, taking time to assess your organization’s true needs
should always be the first step.
• Evaluate coding operations as a whole and identify gaps that
may be causing delays.
• Look at the full picture and formulate a plan for where your
organization is going in the future. Do you anticipate an increase
in claims through increased patient volume? Will you add another
provider or service option (MRI, physical therapy, etc.)?
• Use what you learned about the needs of the organization to
create a list of potential vendors.
Finally, during vetting, look for a vendor who is more than just
a vendor. Everyone who comes into contact with your patient
information must be on the same page, holding to your philosophy
on both patient care as well as your revenue cycle priorities. In
essence, your vendor should be a true partner, and their work and
values should be a seamless extension of yours.
1
“MGMA In Practice Blog.” RSS. N.p., n.d. Web. 17 Apr. 2015. http://www.mgma.com/blog/how-to-avoid-unclean-claims (Published 03-28-14. Accessed 04-16-15.)
2
“How Much Do Medical Practices Pay to Manage the Average Denial?” How Much Do Medical Practices Pay to Manage the Average Denial? N.p., n.d. Web. 17 Apr. 2015.
http://www.medicalbillersandcoders.com/pressrelease_articles.aspx?ArticleId=605 (Published 05-21-14. Accessed 04-10-15.)
3
“MGMA In Practice Blog.” RSS. N.p., n.d. Web. 17 Apr. 2015. http://www.mgma.com/blog/insurance-denials-is-your-practice-to-blame (Published 12-21-11.
Accessed 04-10-15.)
4
“Physicians Prefer Hiring Certified Billers and Coders to Avoid Various Coding Errors and Increase Revenue at Their Clinic!” Physicians Prefer Hiring Certified Billers and Coders
to Avoid Various Coding Errors and Increase Revenue at Their Clinic! N.p., n.d. Web. 17 Apr. 2015. http://www.medicalbillersandcoders.com/coding-update/physicians-prefer-
hiring-certified-billers-and-coders-to-avoid-various-coding-errors-and-increase-revenue-at-their-clinic.html (Published 04-06-14. Accessed 04-10-15.)
5, 6, 7
https://www.aapc.com/resources/research/work-of-a-coder.aspx (Accessed 03-11-15.)