Remark code M90 indicates that the service or procedure is not covered because it has already been provided and reimbursed within a 12-month period, and the policy does not allow for it to be covered more than once during that time frame.
Common causes of code M90 are:
1. The patient has already received the service or procedure within the last 12 months, and the payer's policy does not allow for it to be covered more frequently.
2. There may have been an error in the patient's records indicating that the service was provided twice within a year when it was not.
3. The provider may have submitted the claim with incorrect dates of service, leading to the appearance of the service being rendered more than once in the allowable period.
4. The claim could have been a duplicate submission for the same service, which the payer identified and denied based on their coverage limitations.
5. There might be a lack of coordination between multiple providers, resulting in the same service being billed by different entities within a 12-month span.
6. The payer's system might have inaccurately processed the claim due to a glitch or error, mistakenly identifying it as a service that has been covered within the designated timeframe.
Ways to mitigate code M90 include implementing a robust tracking system for patient services to ensure that procedures or services subject to annual limitations are only scheduled and performed within the appropriate time frame. Educate your scheduling and billing staff about the frequency limitations of certain services to prevent inadvertent resubmissions within a 12-month period. Utilize your electronic health record (EHR) system to set up alerts or flags for services that have been provided, to avoid duplicate claims within the year. Regularly review and update your RCM processes to ensure compliance with the time-based restrictions of services covered by payers.
The steps to address code M90 involve first reviewing the patient's billing and treatment history to confirm the date of the last service that is similar to the one being billed. If the service was indeed provided more than once within a 12-month period, check if there was a medical necessity for the repeated service that might warrant an exception. If an exception is justified, gather the necessary documentation, such as medical records or a letter of medical necessity from the provider, and resubmit the claim with this supporting information. If the service was billed in error, correct the claim to remove the duplicate service and resubmit it. If the service was not covered due to a policy limitation, inform the provider and discuss alternative billing options or services that may be covered.