Question 1

What is a denial risk score?

Accepted Answer

A denial risk score estimates the probability that a CPT+ICD-10 code pair will be denied by insurance. Scores range from low risk (5-10% denial rate) to high risk (>30% denial rate). High-risk combinations need stronger documentation.

Question 2

What causes high denial risk?

Accepted Answer

Common causes: missing documentation, low medical necessity support, code bundling issues, prior authorization required, coverage limitations by insurance plan, or incorrect code pairing (CPT doesn't match diagnosis).

Question 3

How can I prevent denials?

Accepted Answer

1) Use codes with low denial risk. 2) Document medical necessity thoroughly. 3) Verify insurance coverage beforehand. 4) Check for bundling rules. 5) Include clinical notes explaining why this code is medically necessary.

Question 4

What does 'medical necessity' mean?

Accepted Answer

Medical necessity means the service is appropriate, necessary, and effective for the patient's condition based on clinical evidence. Insurance companies deny claims that lack documentation proving medical necessity.

Question 5

Does denial risk vary by specialty?

Accepted Answer

Yes. Different specialties have different denial patterns. A code that's low-risk in cardiology might be high-risk in dermatology. Adjust your interpretation based on your specialty.

Question 6

How accurate is the denial prediction?

Accepted Answer

This tool is based on historical Medicare and commercial claims data. Accuracy is generally 70-80%. Your actual denial rate may vary based on: payer, documentation quality, geographic location, and your specialty's track record.

Question 7

Can I appeal a denial even if risk was high?

Accepted Answer

Yes. High risk doesn't mean automatic denial. If your documentation supports medical necessity, you can appeal. Include clinical evidence, treatment history, and why this service was necessary for this patient.

Question 8

Should I avoid high-risk codes?

Accepted Answer

Not necessarily. If the code is correct and medically necessary, use it. Instead, prepare stronger documentation upfront. Avoiding correct codes hurts clinical accuracy and can cause compliance issues.

Denial Risk Calculator

Hospital Financial Intelligence (Optional)

Loading CPT Database

Related Tools

Reduce Your Risk