Question

Angela, a coder, was informed that an encounter she coded was denied by an insurance company
because medical necessity was not met. The patient was admitted with right knee pain, for which the
provider ordered a right knee x‐ray. However, the patient started having chest pain while waiting for the
results of the right knee x‐ray. The provider quickly took vitals and ordered a chest x‐ray with an EKG to
rule out a heart attack. Both were negative. Angela coded the right knee pain, right knee x‐ray, chest xray,
and EKG, but the claim was submitted to the payer without the chest pain code.

1. Why was the claim denied?

2. What should Angela have done to ensure this claim would be paid?

Answer 1

1 Common reasons for the denial of medical claims are, when the coding is not specific enough, missing of specific information,when claim is not submitted within the time window, incorrect patient information and coding issues. In the above case the claim was denied due to missing information. The patient was admitted with right knee pain, for which a right knee x‐ray was ordered. Chest Xray and EKG claim is not applicable unless the ICD code for chest pain is mentioned, as a patient with knee pain does not require chest xray or EKG otherwise.

2. Co-morbidities or additional diagnosis or symptoms encountered during the course of treatment must also be included while processing the insurance claims. Unspecified diagnosis codes can be an audit trigger if more specificity could be coded.A diagnosis code informs the insurance payer the purpose of a procedure performed. Proper coding and verification of details before submission can ensure guaranteed payments without risk of denial.  An appeal can be forwarded to the payer towards a denied claim but this is a time consuming process. So it is important to cross check and clear all the errors before forwarding the claim to the payer to avoid chaos.