The Power of Fighting Back: Revisiting Surgical Services Denials

By: Briauna Driggers

​Denials related to surgical services continue to be a major pain point for providers, with payers banking on organizations being too busy to appeal. In our follow-up webinar, we revisited the key issues from the first session, expanding on strategies to effectively address surgical denials and ensure proper reimbursement.

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Keys to Understanding Surgical Denials

Understanding CCI Edits & Modifier Usage 

​The National Correct Coding Initiative (NCCI) releases policy manuals set forth by CMS annually to prevent inappropriate payment for services that should not be reported together. They are divided into chapters by code range and split into three categories: procedure to procedure edits, medically unlikely edits (MUE), and add-on code edits. 

Procedure to Procedure Edits
This category of edits includes pairs of codes that shouldn’t (usually) be reported together and is an underlying driver for modifier usage. However, using the right modifiers isn’t always as straightforward as we’d like it be. The webinar explored the difference between Modifier 59, Modifier 25, and X Modifiers, emphasizing how different payers have different requirements.

Medically Unlikely Edits (MUEs)
MUE edits frequently cause denials due to exceeding the maximum units of a code a provider should report on a single day. The maximum can be exceeded based on claim or date of service. The webinar discussed best practices for ensuring compliant reporting and preventing denials.
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Add-On Code Edits
This category of edits describes in more detail what base codes are allowed for each add-on code and when it’s applicable to use them together. During the webinar, the speakers emphasized the importance of only submitting add-on codes in conjunction with the appropriate primary service that is payable.

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​Beyond CCI Edits: Billing for Diagnostic vs. Therapeutic Procedures 

​Not all diagnostic services are billable when performed alongside interventions. Documentation is key, and this session covered when you can (and can’t) separately report a diagnostic angiography in conjunction with interventional services.

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Multiple Procedure Rule & Bundling Issues 

​Reimbursement is impacted when multiple procedures are performed in a single day. Different payers may have different requirements when it comes to the way multiple procedures should be reported in the same 24 hours. During the webinar, we walked through real-world examples of how improper coding and not understanding differing payer policies can trigger bundling issues and denials.

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Assisted Surgery Denials & APPs 

​Many practices face denials when using advanced practice providers (APPs) in surgery due to incorrect modifier use or payer enrollment issues. We discussed how to ensure proper claim submission and documentation to avoid unnecessary denials in these scenarios.

Don’t Let Preventable Denials Sink Your Bottom Line
Surgical services denials can be frustrating, but taking the time to appeal and adjust workflows proactively can make a significant impact. Ultimately, appealing and preventing denials is a team sport that requires input and understanding from coding, billing, and compliance folks. If you missed the live session, you can still gain valuable insights--download the webinar recording today!

Missed part one of our surgical denials discussion? Learn about the complexities of surgical denials.