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Create a Viable Strategy for Resolving Clinical and Coding Denials

As healthcare providers face multiple challenges, such as rising labor shortages and declining reimbursements, they must maximize revenue cycle recovery. Claim denials, a major source of revenue loss for healthcare practices, are on the rise across all payer types. Coding-related denials are a significant source of denials. A thorough and focused denial management medical billing company will aid in reducing revenue loss. This article identifies the sources of revenue leakage due to clinical and coding issues and proposes a comprehensive solution to address them.


Causes of Revenue Loss as a Result of Clinical and Medical Coding Issues

The following are the primary causes of revenue loss in the revenue cycle due to clinical and medical coding issues.


Discharges Have Not Been Fully Billed

Due to DNFB issues, medical practices and hospitals lose 3-5% of their revenue. Healthcare provider organizations lose revenue due to a lack of knowledge of reimbursable procedures or a delay in documenting all medical services provided. Expert medical coders who understand the medical specialty can assist in locating these DNFB problems.

Optimedservices provides one of the best credentialing services to solve your DNFB problems.


Problems With Coding Quality

Denials occur when medical coders incorrectly code a patient-physician encounter. To avoid such denials in the future, healthcare providers must invest in a coding audit function to perform quality checks and improve coding quality by using practice audit and reporting services.


Denials of Clinical Validation

Clinical validation denials are caused by medical codes that do not support the clinical services provided. Better clinical documentation to validate clinical procedures, as well as improved coordination between clinical documentation and coding personnel, are required for an effective appeals strategy for clinical validation denials. Due to increased scrutiny for clinical documentation issues, a healthcare organization must provide compelling documentation as evidence, which often necessitates discussions with physicians.


A Strategy for Effectively Appealing Clinical and Other Denials

Denial management and prevention necessitate effective cross-functional collaboration and ongoing discussions to eliminate the avoidable causes of denials. When denials occur, medical practices and hospitals must implement a coordinated and collaborative appeals strategy that includes the following steps:


Organizational Collaboration

Most denial management experts agree that the first step in denial management and prevention is ongoing analytics on the top reasons for denials. Front-end, HIM & Coding, Back-end, Clinicians, and CDI teams working together will help uncover the root cause of each denial and lay the groundwork for systemic elimination of the identified causes. Clinical coding quality and validation reasons necessitate collaboration between coders and physicians. Clinical Documentation Improvement (CDI) and coding teams must collaborate with physicians to gather clinical evidence to back up the appeal strategy. A regular cadence of meetings between coding and CDI staff can aid in improving coding quality and specificity.


Encourage a Learning Culture

Continuous learning is at the heart of an effective denials management program. To create organizational learning opportunities specific to the type of medical services provided, all stakeholders – front-end staff, clinicians, HIM, and coding personnel – must meet and collaborate.

Outsourcing as a strategy to address coding denials and accelerate the adoption of best practices for shifting focus from denial management to denial prevention can help healthcare organizations supplement their coding and denial management resources.

Healthcare providers must educate their employees about the insurance verification processes. Processing efficiently reduces the likelihood of denials and speeds up the cash flow cycle.

Read More: Advice on Revenue Cycle Management for Medical Practices.

Iqra Haseeb


Organised and efficient Team leading Manager, supporting corporate level officers and senior management personnel with demonstrated expertise in financial and operational leadership. Adroit professional exemplifies multi-disciplinary managerial skills in process procedure and policy improvement initiatives. Accomplished in workflow optimization techniques implementation which increases productivity, reduces labour, and maintains business integrity and quality of service.


Extensive Client Coordination., Conducts business analysis to create value, Provide Support in creating or enhancing the business, Develop and manage strategic partnerships to grow business, Provide Insights or Conduct Studies related to Market or Business Operation related problems, Provide assistance in operating and handling the business, Develop and structure concepts, strategies, automating and scaling the business


Developed and implemented favourable pricing structures balancing firm objectives against customer targets., Education Coordinated innovative strategies to accomplish marketing objectives and boost long-term profitability., Reached out to potential customers via telephone, email and in-person inquiries., Worked with existing customers to increase productivity of  services.

Sharjeel Khan


Having 10 years of experience in the Medical Billing Industry & up to date with Government, Commercial, Automobile & Workers Compensation Payer guidelines throughout the U.S.
Strong knowledge of claims procedures and coding, account receivable/collection, Denial Management, Credentialing/EDI Enrollments and Revenue Cycle Management. Experienced in Electronic Claim (5010) Loop and Segment Editing, Creating Paper to Electronic Claims (EDI 837), Resolving EDI Rejections through Practice Management & Clearing house, creating invoices, customized provider reports, Auditing, processing insurance & patient payments, and pursuing past-due balances through unique & proven RCM process and Data Management.


ICD-10-CM, CPT, Coding Guidelines, Diagnosis Coding, Compliance, Facility/Professional Coding, Complete Revenue Cycle Management, Telehealth or Virtual Visits, Provider Education, CMS-1500, Upper hand in almost every top PM/EMR/EHR Software used, and many more...


Behavioral/Mental Health, Neurology, Family/Internal Medicine, Infectious Diseases, Pulmonary & Sleep Medicine, Pain Management, Physical/Sports Medicine and Rehabilitation (Physiatrist), Chiropractic, Podiatry, Radiology, and much more.

The Full-Service Bundle includes;
  1. Medicare for both one practice county and one provider
  2. Medicaid for both one practice location and one provider
  3. BCBS PID for both the practice and one provider
  4. RailRoad Medicare for both one practice county and one provider