The payer says the records do not support this many units or visits.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Usually recoverable. Appeal it. The money is usually there.
In the order we see it.
Timed-code minutes do not support the units billed under the 8-minute rule.
Documentation does not show the services as separately identifiable.
Frequency exceeds what the payer's policy allows for the diagnosis.
Appeal with the timed-code minutes and daily notes. Check the 8-minute rule maths first.
The documentation, not the argument.
Daily treatment notes with start and stop times, or total timed minutes.
The plan of care showing the frequency was ordered and justified.
The common mistake. Do not resubmit the same units without recalculating the minutes first. If the maths does not support them, the appeal fails on the same ground.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound