Remark code M105 indicates that the documentation provided does not substantiate a disruption in the patient's treatment. The available medical records do not justify the necessity for the billed item. Consequently, payment has been authorized at a decreased rate, and there will be no initiation of a new capped rental period for the equipment.
Common causes of code M105 are:
1. Inadequate documentation that fails to justify the medical necessity for the continuation of therapy or the use of the billed item.
2. A gap in the treatment timeline that suggests a break in therapy, which is not supported by the patient's medical records.
3. Submission of claims for equipment or services without proper evidence of ongoing use or need, as per the payer's coverage guidelines.
4. Lack of a clear, documented progression or change in the patient's condition that necessitates the billed item.
5. Failure to provide updated clinical information when requested by the payer to validate the necessity of a new rental period for durable medical equipment (DME).
6. Incorrect billing practices, such as billing for a new rental period without meeting the criteria for a new benefit period.
Ways to mitigate code M105 include ensuring that all patient records are meticulously documented, particularly regarding therapy sessions and their outcomes. It's crucial to establish and record a clear medical necessity for the continuation of therapy, with detailed progress notes that reflect any changes in the patient's condition that would warrant a break in therapy.
Regularly reviewing and updating the treatment plan to reflect the current clinical situation can also help justify the need for the billed item. Additionally, providing comprehensive documentation that includes the dates and reasons for any breaks in therapy, as well as the rationale for resuming or altering treatment, can support the claim and prevent this code from being applied.
It's also advisable to stay current with payer-specific guidelines on therapy services and equipment rental to ensure compliance with their requirements for initiating a new rental period.
The steps to address code M105 involve several key actions to ensure proper claim resolution. First, review the patient's medical records to confirm the details of the therapy and the necessity for the billed item. Ensure that the documentation clearly indicates the medical reason for the break in therapy and supports the use of the item. If the documentation is insufficient, update the records with the necessary information and resubmit the claim with a detailed explanation or a letter of medical necessity.
Next, if the documentation is already comprehensive, consider reaching out to the payer to discuss the specifics of the case and understand why the break in therapy was not considered justified. Provide any additional information or clarification that may help the payer reassess the claim.
If the payer maintains their decision, explore the possibility of an appeal. Prepare a formal appeal letter, including all relevant medical documentation, a detailed explanation of the break in therapy, and any supporting evidence from clinical guidelines or literature that justifies the necessity of the item.
Lastly, educate the billing and clinical staff on the importance of detailed and accurate documentation to prevent similar issues in the future. This may involve training on specific documentation practices that support the medical necessity of items and services provided to patients.