by John Yodonise

August 23, 2020

PT Billing Services Claim Denials Graphic

Clean claims are the holy grail of medical billing. Unfortunately, in Physical Therapy billing, there are a greater number of claim denials than in any other specialty practice.

Why are claim denials so much greater in Physical Therapy? It is not because Physical Therapy claims are more complicated than other specialties, Rather, it is due to the number of hoops that Physical Therapists must jump through to get a claim paid.

Here are 5 reasons for claim denials in Physical Therapy and how to resolve them.


#1 - Diagnosis Coding Errors

With the introduction of ICD-10, the number of claim denials for diagnosis coding errors has increased significantly.

The old ICD-9 codes were very basic and general in nature. for example 719.46 - Pain in Knee. You did not have to specify which knee or the condition causing the pain in the coding.

The new ICD-10 codes are much more specific, for example M25.562 for pain in left knee. There are also ICD-10 codes for pain in right knee, bilateral knee pain, and pain in unspecified knee.

Solution:

Make sure you purchase a good ICD-10 manual or use software that will correctly code the diagnosis. One of the biggest problems is the use of Unspecified codes, many insurance companies will deny a claim that includes an unspecified code. 

Also, make sure the main diagnosis is in the first code position on the claim because this will also cause a claim denial.


#2 - Verification of Benefits and Eligibility

Many insurance companies are forcing Physical Therapy practices to use online verification and eligibility portals that are not designed to give you all of the information you need for physical therapy claims. The lack of full disclosure is causing an increasing number of claim denials when verifying benefits and eligibility.

You can get basic information but usually you cannot get information about billing codes not covered, number of visits used for the year, and whether they are under a home care plan.

Solution:

We encourage providers to call the insurance companies for benefits and eligibility as much as possible. It is also a good practice to check eligibility on a routine schedule, perhaps monthly, to make sure the patient still has insurance coverage, and not just before the first visit.

It is important to get the correct copay, coinsurance and deductible information so the front desk can collect the correct amount of money from the patient on each visit. You will be amazed at how many times the insurance company will misquote these numbers.

It is also a good idea to ask about per-authorization, authorizations, and any visit or monetary caps that exist. There is nothing worse than not knowing the patient has a limit of 20 visits per year after you have treated them for 30 visits.

You should also ask about any limits to the number of codes or total visit time that may exist. Some insurance companies limit the number of codes to 4 or total visit time to 1 hour. United Healthcare recently added a Maximum of 4 Units of Timed Codes edit to their system and instead of denying any timed codes over 4 units, they reject the entire claim.


#3 - Data Entry Errors and Billing Errors

A significant number of claims are denied due to simple errors for missing or incorrect information and duplicate claims being submitted.

Solution:

It is important that the Patient's Name, Date of Birth, and Insurance ID Number match their insurance card EXACTLY or the claim will be denied. Double check the Insurance ID number by reading it backwards to make sure it is correct.

Make sure the primary diagnosis code is in the first code position.  If multiple codes for a single condition are required, the ICD-10 manual will indicate which code must be the primary code.

Selecting the correct insurance company is vital. For example, if the patient has an out-of-state Blue Cross insurance plan and the card says to submit the claim to the local Blue Cross company, you must select the local Blue Cross company not the out-of-state Blue Cross company.

If the insurance company requires a referring physician, make sure you spell the name correctly and include the correct NPI number for the physician. There are many NPI Lookup programs on the Internet that you can use to verify the referring physician's information.


#4 - Lack of Medical Necessity

Medical necessity is a reason for claim denials. Insurance companies will deny claims if they feel physical therapy is no longer reasonable nor medically necessary.

Some insurance companies will set an arbitrary number of visits allowed based on the diagnosis supplied by the therapist. After the maximum number of visits is reached, you may need to submit your notes for a medical review and authorization before you continue to treat the patient.

Solution:

Good documentation is your best defense against medical necessity denials. Document the complexity of the treatment and document why treatment is medically appropriate based on the beneficiary's condition.

Several insurance companies are requiring medical notes be included with the claim submission and some are going so far as to require the medical notes from the primary physician as well.


#5 - Misuse or Overuse of Modifier 59

The 59 modifier should only be used when appropriate. Inappropriate usage is considered abuse and will result in claim denials. Eventually, it set off a red flag and you will be subject to an audit.

We know of several Physical Therapy practices that avoid code combinations that require the 59 modifier because they fear it will trigger an audit. This is unnecessary if your documentation is correct and shows the need for the 59 modifier.

Solution:

The 59 modifier should only be used when there is a need to indicate that the therapist performed a unique procedure independent of the other procedures performed on the same day of service.

Not sure when to use Modifier 59? The National Correct Coding Initiative Edits will show you when the modifier should be used on your claims. Also, if you are using a Physical Therapy EHR program (such as WebPT), the program will let you know if Modifier 59 is needed when entering your billing information.

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