Remark code M111 indicates that reimbursement for chiropractic manipulative treatment has been denied because the patient has declined to undergo an x-ray, which is a required condition for payment of this service.
Common causes of code M111 are situations where a chiropractic provider has recommended an x-ray as part of the diagnostic process, but the patient has declined to undergo the imaging study. This refusal may be due to personal beliefs, concerns about radiation exposure, financial reasons, or a preference for alternative diagnostic methods. As a result, the payer may not authorize payment for chiropractic manipulative treatment because they consider the x-ray to be a necessary component of the diagnostic evaluation to justify the need for such treatment. Without the x-ray evidence, the payer may determine that the treatment is not medically necessary or that the claim lacks sufficient documentation to support the service billed.
Ways to mitigate code M111 include ensuring that patients are educated on the importance and necessity of x-rays prior to chiropractic manipulative treatment. Implementing a protocol to obtain patient consent for x-rays during the initial evaluation can help prevent this denial. Additionally, chiropractic staff should be trained to explain the rationale behind the x-ray requirement, addressing any concerns or misconceptions patients may have. It's also beneficial to have a system in place to document patient refusals clearly in their health records, which can be referenced in case of an audit or dispute.
The steps to address code M111 involve first communicating with the patient to understand their reasons for refusing an x-ray. Educate the patient on the importance of the x-ray in assessing their condition and how it impacts their treatment plan. If the patient maintains their refusal, document this conversation thoroughly in their medical record.
Next, review the patient's insurance policy to confirm coverage stipulations regarding chiropractic services without an x-ray. If an appeal is appropriate, prepare a detailed explanation, including any exceptional circumstances or medical justifications for why the treatment should be covered despite the lack of an x-ray. Submit this documentation to the insurer and await their response.
If the claim is ultimately denied, inform the patient of their financial responsibility for the treatment provided.