Remark code M26 indicates that the documentation provided does not justify the necessity for the level of service billed. If any payment has been collected from the patient for this service, or any amount that surpasses the maximum charge for a less extensive service, there is a legal obligation to reimburse the patient within 30 days of receiving this notification.
Common causes of code M26 are:
- Documentation submitted does not justify the level of service billed: The healthcare provider may have billed for a comprehensive service, but the medical records or other documentation provided do not support the necessity or complexity of that service.
- Incorrect coding: The provider may have used a procedure code that is too advanced or specific for the service that was actually performed, leading to a discrepancy between the service provided and the code used.
- Lack of medical necessity: The services rendered may not meet the payer's criteria for medical necessity, which can result in a denial for the level of service billed.
- Upcoding: This occurs when a provider intentionally or unintentionally bills for a higher level of service than what was performed, which can be seen as fraudulent or abusive billing practices.
- Insufficient detail in documentation: The healthcare provider's notes may lack the required detail to substantiate the level of service claimed, such as the duration of the patient's visit or the complexity of the medical decision-making involved.
- Billing for a service not covered: The service provided may not be covered under the patient's current insurance plan at the level billed, leading to a denial.
- Modifier misuse: If a modifier is required to accurately represent the service provided and it is not used or used incorrectly, this can result in a denial for the level of service billed.
- Overlapping or duplicate claims: If the same or similar service was billed previously or is part of another claim, the payer may reject the level of service billed due to perceived duplication.
Providers should carefully review their coding and documentation practices to avoid these common causes of denial and ensure compliance with payer requirements.
Ways to mitigate code M26 include ensuring that the documentation for the service provided is comprehensive and clearly justifies the level of service billed. This can be achieved by:
- Training providers on proper documentation practices that align with the level of service codes.
- Implementing a robust review process where coding and billing staff cross-check the documentation against the billed services to confirm that the level of service is supported by the patient's medical records.
- Utilizing clinical decision support tools that guide providers in selecting the appropriate level of service based on the patient's condition and the care provided.
- Regularly auditing a sample of claims to identify patterns that may lead to this code and addressing any issues found.
- Establishing clear communication channels between providers and coding staff to clarify any ambiguities in documentation before claims are submitted.
- Keeping up-to-date with payer-specific guidelines and requirements for different levels of service to ensure compliance with their standards.
The steps to address code M26 involve a thorough review of the patient's medical records and the documentation supporting the level of service billed. Ensure that the documentation clearly demonstrates the medical necessity and the specific reasons why the higher level of service was required. If the documentation is insufficient, enhance it by adding detailed notes and any missing information that substantiates the need for the service provided.
Next, resubmit the claim with the additional documentation and a cover letter explaining the reasons for the higher level of service. If the service level cannot be substantiated, adjust the billing to reflect the appropriate service level that aligns with the documentation.
In the case where an overpayment has been collected from the patient, calculate the amount that needs to be refunded. Issue a refund to the patient within the required 30-day period, and provide a clear explanation to the patient regarding the reason for the refund. Keep a record of the refund transaction for compliance and auditing purposes.
Finally, review your practice's coding and documentation processes to prevent similar issues in the future. Provide additional training to staff if necessary to ensure that the level of service is accurately documented and billed.