Question

Angela, a coder, was informed that an encounter she coded was denied by an insurance company
because medical necessity was not met. The patient was admitted with right knee pain, for which the
provider ordered a right knee x‐ray. However, the patient started having chest pain while waiting for the
results of the right knee x‐ray. The provider quickly took vitals and ordered a chest x‐ray with an EKG to
rule out a heart attack. Both were negative. Angela coded the right knee pain, right knee x‐ray, chest xray,
and EKG, but the claim was submitted to the payer without the chest pain code.

1. Why was the claim denied?

2. What should Angela have done to ensure this claim would be paid?

Answer 1

1.The claim was denied because Ms. Angela didn't mention about the chest pain patient was having while waiting for the knee xray results.

Accurate and complete clinical documentation during the patient encounter is critical for medical billing and coding. If a service provided is not sufficiently documented by the providers, the organisation could face a claim denial or potentially write- off.

2.Angela should have documented properly about the chest pain complaint of the patient, in order to justify the need of chest xray and EKG.