The bane of every physician's practice is when payers deny claims. There are numerous reasons why payers deny claims, with the predominant reason being a paperwork error. Other reasons include misunderstanding on the part of the insurance company, the physician or the patient. There are four key elements in appealing claims that have been denied. They are:

  • Coding,
  • Contracts,
  • Process, and
  • Laws

This article will look at how understanding these four elements are essential to minimizing denials.


It's vital that physicians and their staff members know how to code properly. In October 2015, ICD-9 shifts over to ICD-10, further emphasizing the importance of proper medical coding. In ICD-10 the code is built onto the physician notes, making an Electronic Medical Record (EMR) that much more vital.

Of particular importance are modifiers. Many different modifiers come into play in various specialties, but these six have prominent significance.

-25: This modifier indicates that significant, but separately identifiable Evaluation and Management (E/M) service was performed the same day as a procedure. For example, if a patient comes in with multiple complaints, but decides to postpone some of the procedures for a later date, you use the -25 modifier for the procedure you performed that day. If they come back later for an injection or some other procedure, the -25 modifier doesn't apply to the second visit.

-59: The -59 modifier indicates that two separate procedures at different anatomic sites were performed on the same day and that those procedures are unrelated. Current Procedural Terminology (CPT) describes it as:

"Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician."

This modifier is often used incorrectly. Its primary purpose is to identify that two or more procedures are performed at different anatomic sites.

-58: This modifier is for a procedure that was planned prospectively or is related to a failure of a lesser procedure. According to the American Academy of Orthopaedic Surgeons (AAOS), it is most commonly used in three situations.

1. The second procedure is planned or expected to manage the underlying condition.

2. The second procedure is more extensive, but needed to treat the underlying disease or condition.

3. Therapy or therapeutic procedures are planned following a surgical procedure.

-80: The -80 modifier is used when an assistant surgeon was needed and appropriate during the surgical procedure.

-24: This modifier is used for an unrelated Evaluation and Management (E/M) service performed during the global post-operative period.

-79: The -79 modifier is needed for any unrelated procedure performed during the post-operative period.


Physicians need to understand what is in the contracts they sign with payers. Several contract components are especially important and need to be thoroughly evaluated.

Elements. What are the responsibilities of the health care provider? What are the responsibilities of the health plan? Understand how you fit into any network you agree to belong to upon signing the contract. Beware of the so-called "Silent PPO" -- when one organization buys or utilizes discounted services from a health care provider without the provider being aware he or she is authorizing it.

Specific Provisions. Most contracts have a lengthy list of specific provisions, such as fee schedule, length of term, timely filing, penalties, timeliness of receipt of payment, all products clause, recoupment and termination. Each of these types of provisions spell out the conditions of reimbursement for provider services and need to be completely understood by the physician.

Compliance With Statutes. It's important to understand various prompt payment Laws, the ability to request and the obligation to pay for medical records. Understanding what procedures the insurer can use to collect and how it can recoup money it may have paid inadvertently can help prevent surprises later on. You also need to know what the statute of limitations are to recoup money paid without intent to fraud. Also understand what the appeals process is for each provider.

Of course, when it comes to contracts, physicians need to understand that they should negotiate them. It's not always easy, but if a health care provider insists on negotiated terms, most insurance companies may eventually be willing to negotiate.

Process for Appeals

Every insurance company, as well as Medicare and Medicaid, has unique appeals processes. The timelines vary from payer to payer.

Typically, the most important aspect of an appeal is to have written documentation that you haven't been paid appropriately. If you don't have the correct documents, you are likely to lose an appeal, which wastes time and resources. It may also open you up to a possible audit if you lose the appeal without documentation.

Most appeals, however, are straightforward and can be conducted by telephone, especially if the problem is clerical in nature. If the problem revolves around medical necessity or involves an operative report, it's better to appeal in writing.


Various state and federal laws govern insurance companies and the appeals processes. By law, insurance companies have to respond to an appeal and do so in a timely fashion. Insurers have to provide a reason why they are denying a claim. Physicians also have the right to a peer-to-peer review for a specific claim.

In a peer-to-peer review, another physician in the same specialty will review the claim with you and assist in evaluating why the claim was denied.


Many denials are due to typographical errors, mis-entries or clerical mistakes. A common reason why denials do not get appealed successfully involves issues of medical necessity.

Physicians don't have to be experts in all areas of payer contracts and coding. Nonetheless, it is the physician's signature on the contract. Reading and understanding the contracts is important for anyone running a business. Having at least a general understanding of coding is vital to running a medical practice. Making sure you get paid by insurers for services you've delivered is an essential aspect of running a successful medical practice.