Why Do Geriatric Claims Get Denied More Often?
The denial problem in geriatrics stems directly from patient complexity. When a physician spends 45 minutes with a Medicare patient managing diabetes, hypertension, chronic kidney disease, and cognitive decline, the documentation must support the level of service billed. But capturing the full scope of that visit in a way that satisfies payer requirements is surprisingly difficult.
The most common denial triggers for geriatric practices include insufficient documentation of medical necessity for extended visits, incorrect sequencing of ICD-10 codes for multiple chronic conditions, missing documentation for care coordination services, and failure to properly bill for chronic care management and transitional care management codes that these patients qualify for.
What Revenue Are Geriatric Practices Leaving on the Table?
Many geriatric practices systematically underbill for the services they provide. Chronic Care Management (CCM) codes, which reimburse for the non-face-to-face coordination that geriatric patients require, are significantly underutilized. Studies suggest that fewer than 20% of eligible Medicare patients have CCM services billed on their behalf, despite the fact that the work is being done.
Similarly, Annual Wellness Visits, Advance Care Planning discussions, and cognitive assessment codes represent billable services that geriatric practices perform routinely but frequently fail to capture. The cumulative revenue loss from undercoding these services can reach hundreds of thousands of dollars annually for even a modest-sized practice.
How Does ICD-10 Sequencing Affect Geriatric Reimbursement?
For patients with multiple chronic conditions, the order in which diagnosis codes are listed on a claim directly affects reimbursement. The primary diagnosis drives the payment rate, and choosing the wrong primary code — even when all listed codes are clinically accurate — can result in lower payment or claim rejection.
In geriatric medicine, this sequencing decision is complicated by the fact that patients often present with conditions that are equally significant. Is today visit primarily about the patient worsening heart failure or their newly diagnosed cognitive impairment? The clinical answer might be both, but the billing system requires a hierarchy that maps to payer expectations.
AI-powered coding tools can analyze visit documentation and recommend optimal code sequencing based on the specific payer reimbursement patterns, helping practices capture the maximum appropriate payment for every encounter.
What Are the Biggest Revenue Cycle Bottlenecks in Geriatric Medicine?
Beyond coding, geriatric practices face several revenue cycle challenges unique to their patient population. Medicare eligibility verification is more complex for patients who may have Medicare Advantage, Medigap, Medicaid dual eligibility, or supplemental coverage. Each combination has different billing rules and prior authorization requirements.
Coordination of benefits for dual-eligible patients is particularly problematic. When a patient has both Medicare and Medicaid coverage, billing errors in determining which payer is primary can result in claim rejections from both payers. Staff must navigate complex eligibility rules that change frequently and vary by state.
Can AI Address the Unique RCM Challenges of Geriatric Medicine?
AI tools designed for revenue cycle management are increasingly capable of handling the specific complexities of geriatric billing. Predictive denial management systems can identify claims at high risk of denial before submission, allowing practices to fix documentation gaps proactively rather than reactively filing appeals.
For geriatric practices specifically, AI can help identify patients who qualify for CCM, TCM, or other care management codes that are currently going unbilled. By analyzing patient records against billing criteria, these systems can flag revenue opportunities that staff might otherwise miss in the daily rush of clinical care.
What Steps Should Geriatric Practices Take to Improve Their Revenue Cycle?
The highest-impact starting point is a comprehensive audit of current billing patterns. Are CCM and TCM codes being billed for all eligible patients? Is visit-level coding consistently reflecting the complexity of geriatric encounters? Are denials being tracked by reason code to identify systemic documentation issues?
Practices that invest in understanding their specific denial patterns and revenue leakage points can then implement targeted solutions — whether that is EHR template updates, coder training, AI-assisted coding tools, or workflow changes that ensure billable services are captured at the point of care rather than reconstructed after the fact.
