DENIAL CODES

Denial code M12

Remark code M12 indicates if diagnostic tests by a physician include purchased services on the claim, impacting reimbursement.

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What is Denial Code M12

Remark code M12 indicates that when a physician submits a claim for diagnostic tests, the claim must clearly specify whether the services were performed directly by the physician or if they were purchased from another provider or facility. This distinction is necessary for proper claims processing and reimbursement.

Common Causes of RARC M12

Common causes of code M12 are:

1. The claim submitted by the physician includes charges for diagnostic tests that were not actually performed by the physician or their staff, but were instead purchased services from an outside provider or facility.

2. The billing information fails to properly indicate that the diagnostic tests were purchased services, leading to confusion about who provided the service and who should be reimbursed.

3. There is a lack of appropriate modifiers or indicators on the claim that specify the services were purchased rather than performed in-house, which is necessary for correct claims processing.

4. The documentation accompanying the claim does not sufficiently detail the nature of the purchased services, such as the external provider's information, which is required for the payer to process the claim accurately.

5. The claim may have been coded incorrectly, either due to human error or misunderstanding of the billing guidelines for diagnostic tests, especially when they involve purchased services.

6. There may be inconsistencies between the claim data and the physician's records, suggesting that the services were performed by the physician when they were actually purchased.

7. The claim might not adhere to the specific payer's policies regarding the billing of purchased diagnostic services, resulting in the application of code M12.

Ways to Mitigate Denial Code M12

Ways to mitigate code M12 include ensuring that when billing for diagnostic tests, the claim explicitly states if the services were performed directly by the physician or if they were purchased from an outside provider. It's important to maintain clear documentation that specifies the nature of the services rendered. Additionally, implementing a thorough review process to verify that all claims accurately reflect this information before submission can help prevent this code from arising. Training billing staff to recognize and properly code for direct versus purchased diagnostic services is also crucial in avoiding this issue.

How to Address Denial Code M12

The steps to address code M12 involve reviewing the claim to ensure that any diagnostic tests performed by a physician are properly documented. If purchased services are included, they must be clearly indicated on the claim. To resolve this, you should:

  1. Verify the accuracy of the claim by checking the patient's medical records to confirm that the diagnostic tests were indeed performed by the physician.
  2. Determine if any of the diagnostic services were purchased from an outside provider.
  3. If purchased services are part of the claim, ensure that they are clearly identified and that the appropriate documentation is attached to substantiate the purchase.
  4. Review the billing codes to ensure that they accurately reflect the services provided, including any purchased diagnostic tests.
  5. Amend the claim to include clear indications of purchased services if they were initially omitted or improperly documented.
  6. Resubmit the corrected claim to the payer with all necessary documentation and indications as required.
  7. Document the changes made to the claim and store this information for future reference or in case of an audit.

CARCs Associated to RARC M12

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