News: Inpatient coding errors top reason for hospital complex claim denials

According to the American Hospital Association’s (AHA) 2015 fourth quarter RACTrac survey, which included nearly 750 hospitals, shows that 81% of complex denials in the fourth quarter were due to inpatient coding errors—falling between the second quarter (79%), and third quarter (83%) results.

The online survey also shows that the nationwide dollar amount of each complex claim denial averaged $5,427, down slightly from 2014 fourth quarter denial amount of $5,618. While the hospitals surveyed reported that 78% of complex denials were due to an incorrect MS-DRG or other inpatient coding error, 40% of the hospitals claim their largest financial impact came from outpatient coding errors by automated denials.

Of all hospitals surveyed, 49% report appealing RA denials and 39% were able to have denials reversed during the discussion period. Nationwide, 31% of all cumulative claims appealed are still sitting in the appeals process.

RAs conduct claim reviews for all hospitals through computer software to detect improper payments, and complex human examination reviews of medical records and other documentation. Auditors consider improper payments by assessing incorrect payment amounts, incorrectly coded services, non-covered services, and duplicate services.

Editor’s Note: This article was originally published in JustCoding.