Billing and Reimbursement Essentials for CV Professionals-Common Billing Pitfalls & Denials in CV Programs

Video Transcription

Video Summary

Module 3 focuses on common billing pitfalls and claim denials, which often lead to write-offs. A clean claim should result in payment; however, payers may return claims as unprocessable or request more information before denying them. Once denied, quick action is essential due to limited resubmission timelines (60-90 days). Denials can be appealed, but appeals require strong justification.<br /><br />Explanation of Benefits (EOB) documents are key to understanding denial reasons, which range widely—from diagnosis mismatches and missing modifiers to issues with prior authorizations, medical necessity, and timely submissions. Registration errors and insurance eligibility verification are common front-end issues leading to denials. Anticipated denials include unlisted CPT codes, assistant/co-surgeon claims, and similar cases requiring careful documentation and modifiers.<br /><br />A systematic approach to analyzing denials—grouping by reason code, location, or procedure—helps identify root causes and broad fixes, reducing days in accounts receivable and write-offs. Common denial categories include missing info, medical record requests, benefit issues, bundling/modifiers, provider enrollment problems, and duplicates.<br /><br />Specific service types like visits, labs, rhythm tests, implanted devices, cardiac interventions, and pediatric cardiology present unique denial challenges related to correct coding, documentation, and authorization. For example, diagnosis specificity, proper modifier use, and accurate linkage of diagnosis to procedure codes strongly affect payment outcomes.<br /><br />Effective revenue cycle management involves thorough upfront claim scrubbing, real-time eligibility verification, ongoing denial monitoring, timely appeals, and collaboration among clinicians and administrative staff. Prioritizing high-dollar or high-volume denial categories and service lines allows practices to make targeted improvements that enhance reimbursement success and minimize revenue loss.

Keywords

billing pitfalls

claim denials

write-offs

Explanation of Benefits (EOB)

denial reasons

prior authorizations

medical necessity

denial appeals

revenue cycle management

claim scrubbing