Remark code M89 indicates that the service is not covered because it has been provided more than once to a patient under the age of 40, which exceeds the frequency limitations set by the payer's policy for this age group.
Common causes of code M89 are typically related to the frequency limitations imposed by a payer on a particular service or procedure. This code is often used to indicate that a claim has been denied because the service was performed more than once within a period deemed not medically necessary for patients under the age of 40. The specific reasons might include:
1. Preventive or screening services that have age-related frequency guidelines, such as certain types of imaging or laboratory tests, which are not recommended to be repeated within a certain timeframe for patients under 40 without specific indications.
2. Administrative errors where a service was billed multiple times due to a mistake in the billing process, leading to the appearance of the service being rendered more frequently than covered by the payer's policy.
3. Lack of supporting documentation to justify the medical necessity of repeating the service for a patient under the age of 40 within the period specified by the insurance plan.
4. Misinterpretation of the payer's coverage policies by the healthcare provider, resulting in services being provided and billed for more frequently than the policy allows for the patient's age group.
5. Changes in the payer's coverage policies that the provider may not have been aware of or did not adhere to when scheduling the service for the patient.
It is important for healthcare providers to review and understand the specific coverage limitations and medical necessity requirements of the payers they work with to avoid denials associated with code M89.
Ways to mitigate code M89 include implementing a robust verification process to confirm patient eligibility and benefits before services are rendered. Ensure that your billing system includes age verification checks and flags procedures that are typically not covered for patients under 40. Educate your staff on the age-related limitations of certain procedures and incorporate a step in the patient intake process to discuss potential coverage issues with patients. Regularly update your coding practices to align with the latest coverage guidelines and maintain clear communication with payers to understand their policies on age-specific procedure coverage. Additionally, consider developing a system to track the frequency of services provided to patients under 40 to avoid submitting claims for procedures that are not covered more than once within this age group.
The steps to address code M89 involve verifying the patient's age and the service date to ensure accuracy. If the patient is indeed under 40 and the service has been billed more than once, review the patient's medical records and the payer's coverage policy to confirm if an exception or a policy update allows for additional coverage. If an error has occurred, correct the billing record and resubmit the claim with the appropriate documentation. If the service is legitimately not covered, inform the provider and discuss alternative billing options or the possibility of a patient responsibility notice.