r/CodingandBilling

we were just advised we should try splitting any claims over $600 into 2 smaller claims when possible to avoid their longer review/auto denials that we are having issues with.... i guess they do not like a few of the labs we bill (our IDNow flu/covid/strep testing) when its combined with say a MAW visit. the labs are holding up the rest of the claim so they want us to split them, so the labs will be on their own claim that can be held up while the rest of the charges go through easier on their own claim from the same DOS.

sounds great, but they ACTUALLY want us doing this for all UHC claims over $600- not *JUST* when those specific labs are on a claim.... so now essentially any MAW visit that includes a 99214 (which is basically all of them).

is this okay/legal....? i work for a primary care office that is smaller as well. im new ive been coding for over 1 year at this place.

I'm trying to understand the real workflow for administrative denials, especially CO-16 cases where the RARC points to missing or invalid claim information. When you receive one, what do you actually do first? Do you open the claim in your PMS/EHR, make the correction there and resubmit? Or do you ever work directly with the 835/837 files or upload a corrected 837 through your clearinghouse? One thing I'm specifically trying to understand: if a corrected 837 were already prepared for you, would uploading that file to the clearinghouse actually eliminate work — or would you still need/want to open and update the claim in the PMS first? I'm not looking for patient data or examples containing PHI. I'm just trying to understand the workflow from people who actually work these denials.

I keep hearing that CO-16 (missing/invalid info) corrected claims eat a lot of time, and I'm trying to understand why the rework is such a pain in practice. For those of you who deal with these daily, I'd love to hear how it actually goes:

When a CO-16 comes back, what do you open first? The ERA, the payer portal, the original claim? CO-16 on its own barely tells you anything — how much time goes into just figuring out what's actually missing from the RARC?

Do you fix it in the PMS and resubmit, or send a corrected 837 some other way?

Roughly how long does one take you, start to finish?

What's the part that annoys you most?

Trying to get the real picture from people who do it daily, not the textbook version.