Failing to support the acuity of the medical service rendered with coding and documentation is the No. 1 reason payers deny a hospital claim over a coding issue, according to an Oct. 28 report from Hayes Management Consulting.
For the study, the revenue integrity software provider and consultant analyzed $100 billion worth of denials and $2.5 billion in audited claims.
Here are the top reasons for denials related to coding issues, according to Hayes:
1. The health insurer deems the information submitted by a provider does not support the level of service billed.
2. The procedure code is inconsistent with the modifier used or a required modifier is missing.
3. The diagnosis is invalid for the date or dates of service documented.
4. The diagnosis is inconsistent with the procedure.
5. The diagnosis was not covered.