Coding appeals often center around seeking disclosure of the payer’s coding logic. We use wording such as the following to seek clarification of how the coding decisions were made:
“It is our position that any coding denial should be supported by written coding criteria explaining how newly adopted claim edits will be consistently applied to all related claims. Certain state and federal claim processing guidelines require insurers to provide detailed information regarding benefit calculations, all applicable coding methodologies and all applicable bundling processes. Further, new coding edits should be consistent with nationally recognized and generally accepted bundling edits and logic. If your company utilized published coding guidelines to review the claim, please provide the publisher, product name and version of any software used so that we may assess the accuracy of the information to current coding standards.”
What types of responses does your organization get to these types of disclosure requests? We are working on updated to our coding letters and your input is valuable to drafting effective language for these important appeals.