Maximus Confirms Using Second Review Appeals to Correct Billing Errors

Correcting a coding error is as simple as submitting a Second Review appeal explaining the error.

Last year, we discussed the convoluted process to correct billing errors. As we demonstrated, fixing a billing coding error is a frustrating process, at best. In the case of a missing CPT code, providers can submit a new bill with the missing CPT code.

But what about situations where the original bill contains a coding error? For example, a missing modifier?

Three Compliant Steps to Correct a Coding Error

To correct an original bill submitted with a coding error, DaisyBill recommends using the Second Review appeals process -- and Maximus agrees.

  1. Upon receipt of an EOR if a provider determines that the payment is incorrect due to a provider coding error, the provider thereby “disputes the amount of payment” and the provider needs to request a second review.
  1. Per § 9792.5.5 (a) If the provider disputes the amount of payment made by the claims administrator on a bill for medical treatment services or goods rendered on or after January 1, 2013, submitted pursuant to Labor Code section 4603.2, or Labor Code section 4603.4, or bill for medical-legal expenses incurred on or after January 1, 2013, submitted pursuant to Labor Code section 4622, the provider may request the claims administrator to conduct a second review of the bill.
  1. When submitting the request for Second Review, the original bill CANNOT be altered.
  1. Per § 9792.5.5 (d) The request for second review shall include: (1) The original dates of service and the same itemized services rendered as the original bill. No new dates of service or additional billing codes may be included.
  2. Per the California Electronic Medical Billing and Payment Companion Guide “All elements, fields, and values in the Reconsideration/Second Review bill transaction, except the Reconsideration/Second Review specific qualifiers and Claim Supplemental Information PWK segment, must be the same as the original bill transaction.”
  1. On the Second Review form the provider needs to explain the original coding error, explain the correct coding and the reason for additional payment.
  1. Per § 9792.5.5 (d)(2) In addition to the bill as modified in this subdivision, the second review request shall include, as applicable, the following:
  1. (A) The date of the explanation of review and the claim number or other unique identifying number provided on the explanation of review
  2. (B) The item and amount in dispute.
  3. (C) The additional payment requested and the reason therefor.
  4. (D) The additional information provided in response to a request in the first explanation of review or any other additional information provided in support of the additional payment requested.

Original Bill With Missing “Modifier 59”

By following the three-step process described above to correct an erroneous original bill, generally the claims administrator will reprocess the bill as requested and the provider receives the correct payment. But what if the claims administrator doesn’t reprocess the bill as requested and a provider must file an IBR? Below, we highlight an overturned IBR decision where a provider did just this.

In the series of events that led to the decision in IBR Case Number CB18-0001168:

  1. The original billing was missing a “-59” modifier for CPT code 96101 (which is applicable only to pre-2019 dates of service).
  2. The bill reviewer argued in its response that the use of 96101 was incorrect, as it was bundled in with 99205 for that DOS. The bill reviewer was correct because, absent the modifier, the code is indeed bundled.
  3. Subsequently, the provider attempted to correct its omission by filing a Second Review appeal and included the wayward modifier, pointing out that the modifier allowed an unbundling of the CPT code and made it a distinct procedural service.
  4. In response, the bill reviewer denied further reimbursement; again citing its original rationale. In other words, the bill reviewer ignored the new information that the provider provided.  
  5. At this point, the provider had no choice but to file for Independent Bill Review (IBR).  
  6. In response to the IBR filing, the claims administrator stated: “provider should have submitted a new bill to carrier with Modifier 59.”
  7. Thankfully, Maximus did not agree and overturned the claims administrators original processing of the bill, awarding the provider the balance due per the OMFS as well as reimbursement of the $195 filing fee.

 

In this instance, Maximus’ reasoning is clear and affirms that applicable modifiers added to the Second Review appeal rectified its initial omission; Maximus did not accept the claims administrator’s contention that “Provider should have submitted a new bill to carrier with Modifier 59.”

The moral of the story: When a coding error occurs, don’t despair. The Second Review appeals process works. The icing on top is that it’s supported by Maximus’ cadre of IBR decisions overturning payers’ denials. Using DaisyBill’s IBR Decision Search, we quickly found six pages of Maximus decisions overturning payer denials involving modifiers.

 

Though the expected outcome is generally in the provider’s favor, securing reimbursement for the IBR fee despite Maximus’ order is another matter entirely. We hope filing a lien to recover the IBR fee won’t be necessary, but the ball is back in the payer’s court to do the right thing.

Payers can quickly and easily navigate the Second Review appeals process with DaisyBill’s powerful billing platform. Three clicks is all it takes to create a Second Review appeal and avoid duplicative billing pitfalls along the way. For both payers and providers, our Work Comp Wizard also includes a searchable database filled with IBR decisions that illuminate existing precedent. Sign up for a free demo today and see how DaisyBill makes molehills out of mountains.

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