Untangling the Complexities of Surgical Denials

By: Briauna Driggers, Mary Early Suhr, MBA, CPC, Ashley Carson, CPC, CCS-P, and Juan Arredondo

Surgical procedure denials, particularly during the global period, can create substantial obstacles for healthcare practices—disrupting revenue flow and causing administrative headaches. In our recent webinar, we addressed these challenges head-on, providing solutions to help you manage denials and ensure accurate reimbursement. ​

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The Root of the Problem: Communication Breakdown

One of the major issues uncovered during the webinar was the communication gap between coding and revenue cycle teams. Effective communication between these departments is essential to ensuring claims are accurately processed and denials are minimized. From scheduling a surgery to handling denials, someone needs to understand the entire process and facilitate smooth hand-offs between teams. 

​Our expert panel emphasized the importance of developing a communication workflow that allows information to move seamlessly between coding, scheduling, and revenue cycle management. This collaboration is key to spotting potential problems before they lead to denials. ​

Getting Authorizations Right the First Time

Another critical issue we discussed was authorization denials. Miscommunication and lack of detail during the authorization process can lead to denied claims or misaligned authorizations that don’t reflect the full scope of the surgery. A proactive approach—where both clinical and administrative teams work together—is vital. 
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Authorization denials often occur when there’s a disconnect between what was coded, what was authorized, and what actually took place during the surgery. Our webinar revealed the benefits of authorizing a range of codes, ensuring that the surgical documentation aligns with what’s been approved and avoiding the need for rework or denials. 

Mastering Modifier Usage: A Game-Changer for Coding Accuracy

Bundling and coding denials are common, especially when using incorrect modifiers for assistant surgeons or co-surgeries. During the webinar, we broke down the nuances of modifiers like 80, 81, 82 and AS, explaining when to use each and how they can impact your reimbursement rates. 

Modifier usage is not one-size-fits-all. It varies by payer, meaning that what works for one insurance company may not apply to another. To make it easier, we provided real-life examples and strategies to ensure your claims meet each payer’s specific requirements. 
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Also discussed was what to do in cases where there are residents and fellows participating in the surgery, including how to document their presence and especially their absence when trying to bill for an assist-at-surgery. 

Navigating Non-Covered Denials

Non-covered denials are frustratingly common. Our webinar delved into the trends behind these denials, especially for surgical procedures involving assistant surgeons. Many denials are linked to incorrect CPT code selection or misinterpreting the guidelines for billing assistant surgery charges. By understanding which procedures require additional documentation, such as medical necessity notes, you can increase the likelihood of approval. ​

Global Surgical Period Denials: Avoiding Common Pitfalls

Lastly, global surgical period denials were a key focus of the webinar. Incorrect use of Modifiers 57 and 25 can lead to denials if they are not properly supported by documentation. For instance, Modifier 57 should be used when the decision for surgery is made and performed either on the same day or the next, while Modifier 25 applies to office visits where a minor procedure is performed but is unrelated to the decision for surgery. Our experts stressed the need for detailed documentation to justify the modifier usage and avoid these denials. ​

And the Best Part... ​

We are going to have a second part of this session in January 2025 which will cover Bundling and Non-Covered for Medical Necessity Denials.   ​

Wait, that's not the best part!

At the end of the second session, we will send out tip sheets on how to go from the initial denial remit to payment by evaluating the true reason for the denial with decision trees.  Look for more information on that coming soon, and don’t forget to tune into the inpatient and outpatient webinars coming in October and November of this year. 

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Ready to improve your surgical claim approval rates but missed the live session? You can still benefit from the insights shared! Complete the form above or click here to access the full webinar recording.