Top Reasons Physician Practices See Unexpected Claim Denials

Seeing more than your fair share of denied medical claims?

Increase the chances your medical practice will keep more of the revenue you earn by focusing on 5 commonly denied procedure codes — and the reasons driving the denials.

Analysis of electronic remittance claims submitted in the final 3 months of 2014 reveals the most commonly denied procedures:

  • ‘Outpatient doctor visit, level 3’ (CPT code 99213)
  • ‘Outpatient doctor visit, level 4’ (99214)
  • ‘Routine blood capture’ (36415)
  •  ‘Subsequent hospital care’ (99232)
  • ‘Therapeutic exercises’ (97110)

Family medicine, internal medicine and pediatrics essentially tied for specialties with the most unexpected denials at 10% each, according to this study from RemitDATA. Radiology and orthopedic surgery followed closely behind.

Beware the Bundle

Denial reason codes include:

  • “Duplicate claim/service” tops the list of reason codes behind the most commonly denied procedures (reason code 18)
  • While bundling services may save you money on your cable bill, bundling your CPT codes could cost you. Unexpected denial caused by coverage within a bundled service — officially known as claim adjustment reason code 97 — was the #2 reason for claim denial, according to a Physicians Practice infographic of the study results.
  • Lack of information or medical billing error (reason code 16)
  • Non-covered charges (code 96)
  • Care possibly covered by another payer (code 22).

Using the right modifier can boost your medical revenue cycle by helping to avoid claim denials, especially to justify a distinct procedure typically billed within a bundled service.


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