Re: Related to Reason Codes

[Steve Verno]

I hope you get something out of your training. 

But, you still havent answered my question.   Are you doing HHA billing???

Not giving you what you want is not insulting.  As I said, we cant do this for you.  THis requires someone with a knowledge of coding, compliance, billing and Medicare, and knowledge of the account itself.  THis project of yours is bigger than you can understand.  also, forums are not training sites.  We provide guidance only.  We're not here to insult you. 


Example:

Claim for Leonard McCoy.  Sent to Medicare with XXXXX (no modifier) and YYYYY and modifier 59.  (First, this is coded wrong)  Claim denied with C23 No authorization obtained.  YOu need to check your LCD to see if this is a service that requires authorization. YOU have it.
You submit an appeal which someone with coding, billing and medicare experience can prepare and send.  If this was denied for coding reasons, this needs to be fixed by the coding department.  The problem could be your coders do not have the proper training. 

Next you have the claim for Montgomery Scott.  Billed XXXX with modifier 35 and YYYYY with no modifier.  In this case coding training and NCCI shows no bundling so you are safe but another modifier is missing.  Medicare denies s66, benefits have expired.  You need to check the file to see if an ABn is on file. If so, then your decision is to bill the member, if not, the decision is to adjust the account to a zero balance and meet with the provider regarding ABNs and the coding department regarding missing abns and modifiers.

Note:  Denial codes are fake and made up for the puspose of this post.

I did this to show that this is NOT a simple task.  THis is a compliance issue and should be done with co-assistance from your coding department and compliance officer.  You cant just put down bill the member.  There are other circumstances involved.  You're looking at changing your billing and coding practices.  YOU also need your local medicare LCDs, Current NCCIs and the Medicare appeals process.

YOU also have to look at your coding and billing processes.  If youre doing HHA coding and billing with no knowledge of HHA coding and billing, your task will be impossible to complete, because that is where your problem exists.  Training is your cure.

OK, lets look at this again,  you are a data entry employee and you process EOBs and you dont understand what you see.  This is because you were probably hired for data entry, not billing. You are confused at what you see.  That is because you dont have the proper training to interpret what you see.  Its good you want to expand your knowledge, but you should do this the right way by taking a billing course instead of trying to teach yourself through a forum.  The other alternative is to stick with data entry and not interpet what you see.   Leave that to the trained professionals and leaders in your company or ask your leaders to teach you. Those denials will probably be given to employees whose job it is to work those denials.  Your desires are honorable, but in this business, you need to do things the right way and that is through proper training. Self training today may only confuse you more. 

Thats all Im doing for free. Remember, I made mistakes and I learned from them. This is as far as I go.  Will I be willing to be hired to work with your company on this?  Remember my mistakes. No!  Go back to your boss and let him/her know you wont be able to meet his request.  Last, you will see once you undergo your training.  What cant be seen now will become more clear. 

[Steve Verno]

Koolest Girl

Im a very blunt person so, what I say is not insulting. Why is it when you dont get what you want, you consider it as insulting?

Yes, Those mistakes were mine, I learn from my mistakes. I trusted people back then and I no longer trust those people. That is how I learn from my mistakes.  Learning from my mistakes means I now take caution when I see someone asking for things that dont exist or they want me to do things for them. By learning from my mistake I learned to say NO. So, I am not insulting by asking some questions and by telling a story.  If you deem it insulting, then that seems to be your personal problem.   To me, that is because YOU dont understand me as a person or human being. You see, sharing of information is NOT a right, it is a privilege. A forum is NOT a training institution for you to learn how to do your job or to come to for us to do your project.  Im not being insulting when I say that.

Your request is unreasonable.  We cant look for every denial code, explain what they mean and come up with a course of action on each denial. 

I dont know what specialty you are working for, that is why I asked.  I believe you are doing Home Health billing and coding.  How do I believe this?  Simple. Its your denials from Medicare that is your first clue.  When I said you have problems with coding and billing. That is not insulting.  That is a fact.   How do I know this?  Look at your denials.  Rather than being stubborn and proud, take your head and look at whats happening.

Invalid modifiers and procedure codes (Coding Problem)

Non covered service (Billing and coding problem)

Coordination of Benefits (Billing problem)

What you're asking for is impossible to provide. 

What you need is proper training at all levels.  You cant do specialty billing without knowing the specialty.  Some claims may be paid but down the road, you may face retroactive reviews and refund demands. You admit you dont know what these denials mean. Proper training will correct this. 

We cant teach you HHA coding and billing on a forum.  If I am wrong about the specialty, blame yourself for being stubborn and not answering my questions. 

Stop blaming the forum for not doing what YOU want.  I came here for help and all you do is insult us.   Whats insulting is what you expect out of a forum and if you dont get what you want, you insult back hoping someone will feel sorry and give you want you demand.  I asked some pertinent questions and they have not been answered.

Again, what you ask cannot be done. Its that simple. 

On a side note, other unknown that have not been presented.  How old are these denials? if more than 120 days old, then you have no appeal to do.  It would be a waste of time because appeals sent 120 days past the denial date would be denied. 

[Pay_My_Claims]

Take a medical billing course. The field is huge, and your issues can not be resolved by one question on the forum. In general most people that post here have background in this field, and the administrators operate these boards to assist people that may have a situation that they don't know how to deal with. Your issue is that you have no medical billing background. In order for us to truly assist you, the best answer we can give is to take a medical billing course. If you google medical billing, you will come up with a lot of online classes. Currently my suggestion to you would be to forward the errors to the correct department, and see if your employer has any on the job training programs available for you. If not go for it on your own
Best of luck

[Pay_My_Claims]

No disrespect intended, but you must understand how we feel as US citizens that we are in an economic crisis and jobs are being sent overseas for cheap labor. As we will help anyone that asks, it seems that what you will probably need is adequate training. If you are simply data entry, then what you would be doing is just putting the information into the system, and a denial specialist would be doing that job. The errors you have report to the correct department.

[Steve Verno]

I dove in and someone drained the pool.


Several years ago, a company in India asked me to help them with starting their billing company.  They wanted an employee structure set up, plans such as with HIPAA, Compliance, and SOPs.  It was done with simple e-mails, asking to help develop this and that.  I was nieve at the time.  This came with a promise to reimburse me when they were done.   

The carrot was come to Mumbai and teach our staff in coding and billing.  Naturally, it was buy your own ticket, pay your own hotel bill and we will reimburse you later.  The teaching was approved only when iI brought in sufficient clients for them.  The teaching, they said, was on live data sent by the providers. 

An invoice was sent for the previous work. No check ever came.  I was basically told, Ha ha, we got what we wanted out of you, so go ahead and sue us in your US court,  we're in India and you cant touch us. 

Naturally, the e-mails came, we need you to come here and train us and we need clients badly.  Fool me once shame on you, fool me twice shame on me.  I hold no ill will towards someone from India as my two major doctors come from there and they are great.  My trust in the business practices with someone wanting to start out is lost.  Now, when I get those e-mails, begging for help, which are actually, please do my work for me or please find me clients,  they are declined. 

For example, an e-mail I received in February:

Kindly can you refer me the coding outsourcing companies who are willing to outsource Radiology and/Or Anesthesia or surgery.  Awaiting for your valuable response to proceed further. (I never answered back. I dont have a fancy leather book on a golden pedastal with all of this info available, I am not a headhunter, and I am not going to devote my time for free to look for clients for someone.  MY mind is telling me these people seem to want everything for free.  I know, why pay for the cow when you can get the milkshake for free.  Hey its 3:30am, Im tired, spent my day walking around a mall with my wife so she can look for cutsie things for my sons wedding.  No Hunny, I dont like the pen set with the fancy feather in the pen. Lets go to the Dollar Tree, get a book with blank paper and I have some purple pens from the Conference with the word ***(censored)*** on the pen and that will do the same as the $39 pen set you want to buy.  Mine costs $1.00 for the book.  The pens were free. Then we went to see Night at The Museum. (Its for kids and adults and adults like me who acts like a kid)  I liked it.  Tomorrow or today is Star Trek 2009 again or Terminator and now Im tired and not so coherent. The wife put Titanic on the bedroom DVD and I woke to "Jack!  Come Back!"  being 56, that was my cue to emptying my bladder.   Trying to get sleepy again. (Nope, didnt win the lottery)  I think Ill put Star Trek 6 on and have some warm cocoa.  That makes me tired.  Seen the movie 75 times now cause I like it.) 

MOM!!!!!!!!!!  IM thirsty and I have to go to the bathroom!!!!!!!!  MOM!!!!!!!!!!!!!!!!!!!!!!!!!

[Danni R.]

You see, this is is a prime example where I wonder whether proper vocational training, or training OTJ via a mentor before hand would have made a huge difference! Perhaps, THIS is also a prime example why more and more employers are asking for 1-2 years experience, and sometimes certification.

I believe too many make the mistake and believe medical coding and billing (from home) is easy money, and they dive right in without training, or experience, believing that it will all work out okay. They hope the employer will bear with them (or not find out) while the answers will be handed to them via the Internet... Only to realize, this is NOT benefiting them, their employer, or the business.

It looks like so many others, Koolest Girl just found herself in a catch-22 dilemma.

Okay... I could be wrong. Just some food for thought.

[Steve Verno]

Are you a billing company located in India and provides services to US providers?

Just so I can understand, you would like us to provide you with every claim denial codes, what each denial code means and what to do when you get a denial.  I cant seem to understand your post.  its not you, its me.

Example:  S23, Denied for timely filing. Appeal with timely filing appeal.

This was not a real denial code, just an example. 


Also, just looking at your denials several times, you seem to have some other problems with just simple billing and coding. It could be interpreted that your staff is not properly trained.

Also, are you billing for a home health agency???  If so, does anyone in your company have knowledge or experience with HHA?


THis may be something we might not be able to help with as training in HHA may be required to fix the problem and we are not a teaching agency or organization.