This document discusses various types of denials including inclusive, mutually exclusive, comprehensive and component codes. It provides examples of inclusive coding and defines mutually exclusive procedures that cannot be billed together. It discusses checking CCI edits, commercial websites, and encoder software to determine correct coding. Reasons for denials include missing or incorrect modifiers, downcoding, and billing higher and lower level codes together. Modifiers and their appropriate uses are outlined. Global periods are defined as pre and post-op care periods after a procedure to avoid separate billing.

1. INCLUSIVE DENIAL
Denial Series

2. INCLUSIVE
Definition
• Bundling or inclusive is a payment method
that combines minor medical services or
surgeries with principal procedures when
performed together or within a specific period
of time.
Examples: 71010 (Single View) inclusive with
71020. (Two view)

3. MUTUALLY EXCLUSIVE
Mutually Exclusive:
 Mutually Exclusive Procedures are
procedures that cannot be reasonably done
in the same session
Ex: CPT 81002 when billed with 81000 will be
denied 00.
CPT 81000 Urinalysis by dip stick or tablet reagent
;Non automated with microscopy
CPT 81002 Urinalysis by dip stick or tablet
reagent ;Non automated without microscopy

4. Denial Verifications
• CCI Edits – CMS/ BCBS
• McKesson's Edits – Aetna, Cigna, HIP
• Commercial Web sites
• Code correct
• Encoder Pro.

5. Comprehensive & Component
Codes
• The component code will not be paid
when it is rendered by the same provider
on the same date of service because it is
considered to be part of the
comprehensive code

6. McKesson's EDITS
•

7. McKesson's EDITS
•

8. McKesson's EDITS
•

9. McKesson's EDITS
•

10. NATIONAL CORRECT CODING INITIATIVE
(NCCI)
• Medicare established the CCI in Jan 1, 1996.
• CCI sets standards for billing with CPT & HCPCS
codes.
• The CCI identifies mutually exclusive codes or
those that should not be billed together.
•CCI was introduced to:
• Establish standards of medical billing. Identify codes
that may be a potential for fraud & abuse.
• Identify codes that are components of another code
& should not be unbundled & billed on the same
encounter by the same physician

11. REASONS FOR THE DENIAL
•No modifier used when billing the claim.
•Incorrect modifier used.
•Down coding by the insurance.
•When a higher complex CPT is billed along
with the lower complex CPT for the same
diagnosis.

12. MODIFIERS
Modifiers are codes that are used to “enhance or alter the
description of a service or supply” under certain circumstances
A modifier is a two-digit code that further describes the service
performed
Modifiers may be used under the following
circumstances:-
A service or procedure has both a professional and technical
component.
A service or procedure was performed by more than one physician
and/or in more than one location.
A service or procedure has been increased or reduced.
Only part of a service was performed.
A bilateral procedure was performed.
A service or procedure was provided more than once.

13. LIST OF MODIFIERS

14. Precall Analysis
 Check if any related CPT is billed on the same day
by provider of same specialty
 Check the RVU value in Software.
 If E & M codes are denied check the Global period
for the Surgery codes.
 Check in CCI/McKesson Edits whether any modifier
is applicable to the denied CPT
 Check if the denied CPT is billed with appropriate
modifier, included in the other CPT

15. CLAIM DENIED BY MEDICARE AS
BUNDLED

16. CLAIM DENIED BY MEDICARE AS
BUNDLED
Filter by DOS

17. Encoder Pro

18. Encoder Pro

19. Encoder Pro

20. Encoder Pro

21. CCI EDITS

22. Denial Resolutions
Check the flow chart
Status & action Code
IPP – TAP- Telephonic Appeal
PWO - Potential Write off,
MRR - Medical record request
APL - Appeal

23. Global Periods

24. Global Package

25. Global Period
The pre-op and post-op care the
patient receives by the physician after
a procedure

26. Global Period
Are determined by the type of
procedure
The time frame is different by payer
Do not apply to all procedures

27. Why Global Periods??????
It would save on processing
separate bills
You would be reimbursed for the
entire service in one payment

28. Thank You