Denied claims have a huge impact on surgery centers. Here are the top 10 procedures performed at ambulatory care facilities by total billed amounts from Nov. 15, 2012 to Feb. 11, 2013, and the denial rates for each procedure based on data collected by RemitDATA, an independent source of comparative analytics for reimbursement, utilization and productivity data. The database houses 25 percent of all national outpatient remits.
1. Proton treatment simple with comp.: 10 percent
2. Proton treatment intermediate: 10 percent
3. Cataract Surgery With IOL 1 Stage: 7 percent
4. Upper GI/Endoscopy Biopsy: 8 percent
5. Provide INR Test Mater/Equipment: 10 percent
6. Stereoscopic X-Ray Guidance: 6 percent
7. Office/Outpatient Visit, Est. (CPT 99214): 9 percent
8. Office/Outpatient Visit, Est. (CT 99213): 7 percent
9. Radiation Tx Delivery Intensity Modulated Radiation Therapy: 14 Percent
10. Colonoscopy and Biopsy: 9 percent
Here are the top 10 reasons why the most commonly billed procedures in ambulatory surgical facilities were unexpectedly denied based on data collected between November 5, 2012 and February 11 2013 by RemitDATA.
11. Claims or service lacks information which is needed for adjudication.
12. Duplicate claim or service.
13. Procedure or treatment is deemed experimental or investigational by the payor.
14. The benefit for this service is not included in the payment or allowance for another service or procedure that has already been adjudicated.
15. These are non-covered services because they are not deemed "medically necessary" by the payor.
16. Pre-certification, authorization or notification is absent.
17. Claims were not covered by the payor or contractor. You must send the claim to the correct payor or contractor.
18. Payment for the claim or service may have been provided in a previous payment.
19. The patient or insured health identification number and name do not match.
20. Coverage or program guidelines were not met or were exceeded.
Here are the top 15 states with the worst denials rates for ambulatory surgery centers based on information from the top 10 ambulatory surgery center codes for unexpected denials, according to RemitDATA.
21. New York — 37 percent
22. Georgia — 27 percent
23. Kentucky — 22 percent
24. Kansas — 21 percent
25. Indiana — 19 percent
26. South Carolina — 17 percent
27. Minnesota — 16 percent
28. Pennsylvania — 15 percent
29. Washington — 12 percent
30. Illinois — 11 percent
31. Maryland — 10 percent
32. New Mexico — 10 percent
33. Virginia — 9 percent
34. Delaware — 8 percent
35. Alabama — 8 percent