Denials in the physical therapy billing process are issues that appears when medical records are rejected or returned due to inaccuracies or uncertainties. This ultimately leads to a sluggish cash flow and poses a threat to healthcare finance. Addressing and reducing denial is critical to a healthcare organization’s financial stability. This article lists the common physical therapy billing denials and their mitigations.

What are common physical therapy billing denials and rejections?

1. Missing Pre-authorization or Exceeding Authorized Visits

Pre-authorization is taking approval from a patient’s insurance company before proceeding certain treatment or services. There is common denial in therapy billing process that there may be lack of pre authorization or excess in verification of patient coinsurance benefits prior. That result in error and ultimately a failure for prior authorization technique. This is often necessary due to high costs or surgical options where Insurers have had to seek prior authorization for physical therapy services before the treatment.

How to limit prior authorization defaults?
To avoid prior authorization or further visits, physical therapists can take the following steps:

  1. Review the patient’s insurance benefits and scope before providing treatment.
  2. Confirm and validate patient information by prior authorization to continue treatment.
  3. Follow authorization with completed sessions. 
  4. Have quality check process for reporting and analyzing patient’s data.

2. Patient Eligibility Verification issues

Even before prior authorization it is important to confirm patient’s validity to ensure health insurance coverage and that their policies are up-to-date to prevent denial and billing errors. Eligibility verification involves checking patient’s insurance policy to assign criteria, to elaborate limitations or exclusions for patient treatment. Additionally insurance companies determine the number of visits allowed based on the doctor’s diagnosis. The procedure includes submission of documents for review and authorization to apportion treatment accordingly.

How to precise patient eligibility is verified?

 In order to avoid eligibility verification issues and ensure proper physical therapy practices can take several steps.

  1. Implement pre registration strategy before treatment to ensure eligibility.
  2. Ensure benefits prior to the patient’s first visit and regular checkup through the course of treatment.
  3. Extract correct co pay, coinsurance and deductible information before front desk.
  4. Limit the number of codes or total visits per year for patient.
  5. Use electronic benefits verification service for quick access.

3. Billing Errors

While taking a Billing audit there are a lot of mistakes and errors, even by most experience and seasoned employee, that is why billing error are ever challenging in physical therapy billing process. Therapy billing is all about billing and reporting without analyzing there are always some common uncertainties. Billing errors lead to certain issues, such as incorrect numbers, missing  of data, data entry issue, issues with insurance or inconsistent patient information, slow cash flow,  delay payment, claim denials, and compliance issues; therefore, appropriate billing systems are critical to financial success in healthcare.

How to emend billing errors?

Following strategy will optimize physical therapy billing safely preventing billing errors:

  1. Bill automation.
  2. Recreate billing process.
  3. Audit the recent billing softwares.
  4. Train staff about automate billing system.

4. RCM causing Coding Errors

Coding errors includes numeric or alpha numeric codes. The most and common error is use of ICD-10 code and use of outdated ICD-9 code. Coding system in physical therapy billing provide ease by allocating a code for a specific diagnoses and treatment. Coding error include common culprits that uses wrong code to describe patient condition and ultimately  physical therapy request is denied, in this way code errors can be serious offensive.

Some commonly encountered denial codes in physical therapy billing include:

CO4 – The procedure code is inconsistent with the modifier used or a required modifier is missing.

CO16 – Claim/service lacks information or has submission errors.

CO18 – Duplicate claim/service.

CO29 – The time limit for filing has expired.

CO50 – These are non-covered services because this is not deemed a “medical necessity” by the payer.

CO97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

CO109 – Claim not covered by this payer/contractor.

How to rectify coding errors?

Following diagnoses would probably precise coding errors:

  1. Manifest correct use of ICD-10.
  2. Avoid use of generic code.
  3. Cross matching of codes.
  4. Track and report denial at first place.

5. Modifier 59 inappropriate use

Modifier 59 is used to encode distinct procedures or services that are independent from other services currently performed. The Centers for Medicare and Medicaid Services (CMS) notify that modifier 59 is frequently misused among the most widely used modifiers, leading to improper payments or denials.  It is often used to indicate that a provider performing two services is usually paid as one, or billed under a single code. Overuse and inappropriate use of Modifier 59 results in claim denials.

How to avoid use of Modifier 59?

  1. Use Modifier 59 according to documentation.
  2. Precisely review billing code and manifest particular modifier.
  3. Regular training on appropriate coding and billing will benefit providers.

6. Patients data entry and accuracy uncertainties  

Patient’s information uncertainty includes lack of details, misspelled name, missing entry or may be incomplete demographic information. These uncertainties give rise to errors in coding, billing, cash flow and claim denial that is why data entry and accuracy is important. Even small errors may cause financial losses to the providers.

How to certain patient’s data?

To avoid data entry errors and ensure accurate patient information, consider the following strategies:

  1. Standardize patient verification and registration process.
  2. Renew manual system instead prefers technology.
  3. Appropriate data entry procedure.
  4. Precise monitoring and reviewing of data report.
  5. Train and motivate team members.

7. Lack of medical necessity

Lack of medical of necessaries refers to services or treatments that are unnecessary to treat the patient’s condition. Unproven treatment method and lack of detail documentation fail to show progress of physical therapy billing. Eventually claim appears to be denied by Insurance companies.

How to overcome unnecessary treatment?

To avoid unnecessary treatment and ensure appropriate documentation, physiotherapists should:

  1. Keep detailed and reliable records of patient’s diagnoses, treatment plans and progress with each treatment.
  2. Awareness among patients related physical therapy effect.
  3. Convince patients of the efficacy of physical therapy by employing evidence-based treatment methods.

Keeping these 7 pointers in mind you can reduce common physical therapy billing denials and rejections.

Thank you!

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