Here are four common CCM denials and how to avoid them.
Payers and the Office of Inspector General (OIG) are starting to crack down on improper payments for CCM. The message to practices is: Focus on accurate coding, or run the risk of recoupments, says Kim Garner Huey, CPC, owner of KGG Coding and Reimbursement Consulting in Birmingham, Ala. Here are some common CCM denials and how to avoid them:
Reason for denial: More than one provider bills CCM for the same patient during the same 30-day timeframe.
How to avoid it: Coordinate care with specialists to avoid duplication, says Huey. This coordination should occur at the physician-to-physician level. The primary care physician and specialist should collaborate and decide who will perform all or a majority of the care management activities, including addressing the patient’s psychosocial needs. This is the provider who should bill the CCM code, she adds.
Reason for denial: The practice bills CCM with home healthcare supervision/hospice care supervision (HCPCS codes G0181 or G0182), certain end-stage renal disease services (CPT codes 90951-90970), or transitional care management (CPT codes 99495-99496) during the same 30-day period.
How to avoid it: Ask the software vendor to include an edit that prevents the practice from billing CCM with these other services, says Huey. Another option is to hold the claim until the last day of the month. Then manually review claims for all patients enrolled in CCM to ensure that the practice hasn’t already billed any of the services listed above.
Reason for denial: The care plan is too generic.
How to avoid it: Document a comprehensive plan of care that addresses all of the patient’s medical needs-not only the two minimum qualifying chronic conditions, says Huey. Avoid using templated language that isn’t specific to the patient, she adds.
Reason for denial: CCM services aren’t appropriate for the patient.
How to avoid it: Explain why the chronic conditions put the patient at significant risk of death or decline, says Huey. For example, one patient may have well-controlled diabetes while another could be uncontrolled or have multiple complications. Always choose the most specific diagnosis code in the EHR, and avoid unspecified codes when possible, she adds.