Remark code M94 indicates that the information provided does not substantiate a disruption in the course of treatment. Consequently, a new capped rental period will not commence.
Common causes of code M94 are:
1. Insufficient documentation to prove that there was a legitimate interruption in the use of durable medical equipment (DME) that would necessitate the start of a new rental period.
2. The patient continued to use the equipment without a break that meets the minimum duration required to establish a new rental period.
3. The claim was submitted without clear evidence of a medical necessity for the interruption and subsequent re-initiation of the rental period.
4. The healthcare provider failed to report a change in the patient's condition that would justify a break in therapy and the need for a new rental period.
5. The time frame between the previous rental period and the new claim submission does not meet the criteria for a "break in therapy" as defined by payer policies.
6. The claim lacks a detailed explanation or proper coding that reflects a patient's hospitalization, transfer to another facility, or other circumstances that could interrupt the rental period.
7. The patient's medical records do not show a discontinuation of the use of the equipment for reasons such as repair, replacement, or because it was no longer medically necessary, which are typically required to reset a rental period.
Ways to mitigate code M94 include ensuring that all documentation accurately reflects the patient's need for a break in therapy and justifies the medical necessity for restarting a capped rental period. This involves maintaining detailed and up-to-date patient records, including treatment plans, progress notes, and any relevant communication with the patient regarding their therapy. It's also crucial to review the billing guidelines for capped rental items to confirm that the criteria for a break in therapy are met before submitting a claim. Additionally, implement a robust pre-claim review process to catch any discrepancies or missing information that could lead to this denial. Regular training for staff on proper documentation practices can also help prevent this issue.
The steps to address code M94 involve reviewing the patient's treatment history to confirm the accuracy of the therapy break. If the break in therapy is correctly documented, gather and resubmit supporting documentation that clearly indicates the necessity and duration of the break. Ensure that the documentation aligns with the requirements for initiating a new capped rental period.
If the break in therapy was not accurately represented, correct the claim information to reflect the continuous therapy and resubmit the claim. Additionally, verify that all billing and coding are consistent with the most current guidelines for capped rental items. If necessary, communicate with the clinical team to obtain detailed notes or additional evidence that justifies the therapy interruption.