Re[2]: Defending medical coding assignments

My opinion is that the insurance carrier doesn't care if it's coded by a
certified coder, coded by the provider, or coded by God. That approach
will not help you win the appeal.

To successfully appeal and overturn the denial, you will need to obtain
the carrier's medical coverage policy (LCD if it's Medicare) showing
their coding guidelines, covered CPT codes, ICD-10 codes, documentation
and medical necessity requirements. Show them their own policy to them
and that you have met their medical necessity requirements, coded using
a covered CPT/ICD-10 code, documented properly, etc. That will do it.

If there is no specific medical policy from the carrier covering the
denial, then your argument should be based on the fact stating that
there are no published guidelines from the carrier stating that this
specific procedure, treatment, diagnosis is not covered. They can't
hold you accountable for something that they haven't told you that need
to be accountable for.. make sense?

Also, it could have been coded, not documented properly. In the appeal,
highlight the pertinent areas of the chart note showing you documented
all the necessary criteria. Remember: If it's not documented, you
didn't do it.


Karl M. Ellzey, President
Ellzey Coding Solutions, Inc.


  • I agree with Karl. I would write appeals and state "reviewed by AAPC certified coder" and it would make absolutely no difference at all. Throwing their own words back at them by attaching their own coverage determinations is more effective.


    Beth Aldridge, CPC

    Coding Manager

    Northern California Medical Associates, Inc

    Phone: (707) 573-6145

    Fax: (707) 573-6932

  • Good advice from Karl

    EB, CCS-P

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