What steps would you take to resolve a coding denial or rejection?

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To resolve a coding denial or rejection, follow these structured steps to identify the issue, correct it, and prevent future occurrences:

🧾 1. Review the Denial or Rejection Notice

• Read the Explanation of Benefits (EOB) or Remittance Advice (RA) carefully.

• Note the denial code, reason, and payer comments.

🔍 2. Analyze the Claim

• Compare the submitted codes with the medical documentation.

• Verify:

  • Correct diagnosis and procedure codes

  • Code sequencing

  • Modifiers (if required)

  • Payer-specific rules

📞 3. Contact the Payer if Needed

• If the reason isn’t clear, call the payer’s support team for clarification.

• Document the call details: name, date, and guidance received.

📝 4. Correct the Error

• Fix coding errors such as:

  • Incorrect ICD-10, CPT, or HCPCS codes

  • Missing or incorrect modifiers

  • Inappropriate code combinations

🔁 5. Resubmit or Appeal the Claim

• For rejections, correct and resubmit the claim.

• For denials, submit a formal appeal with:

  • A corrected claim

  • A detailed explanation

  • Supporting documentation

📚 6. Document the Resolution

• Record the steps taken, outcomes, and communication.

• Update internal systems if policy or payer guidelines changed.

🚫 7. Prevent Future Denials

• Educate coding/billing staff.

• Update coding tools and references.

• Conduct periodic audits to catch common errors.

✅ Summary

Resolving a denial requires investigation, correction, communication, and follow-up—ensuring accurate reimbursement and stronger processes moving forward.

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