Coding denials can take many forms. In some cases, the payer will deny a code on the grounds that it is not covered or not supported by the documentation. HLS can appeal these denials by researching the payer’s coverage requirements. Relying on our knowledge of coding, we can work with your billing department to identify cases in which it may be proper to send a claim for coding review or submit a corrected claim. We can also appeal denials based on DRGs.
Increasingly, we find that payers are reclassifying medical necessity denials as coding denials. When this happens, we address both aspects of the denial in our appeals. We argue that the hospital coded the claim correctly based on its internal policies as well as guidance offered by the payer and by state and federal regulations. We also argue that the services were medically necessary at the level of care that was billed, whether for inpatient or outpatient services.