Remark code M97 indicates that the payment for the service provided will not be made directly to the practitioner because it was delivered to the patient in a specific place of service. Instead, the payment for this service is included in the overall reimbursement that is issued to the facility where the service was provided.
Common causes of code M97 are typically related to billing errors where a service provided by a practitioner is submitted for reimbursement, but the service is one that should be included in the facility's payment. This can occur in situations such as:
1. Incorrect Place of Service (POS) Code: The practitioner may have used a POS code that indicates a facility setting when the payment for their service is actually bundled into the facility fee.
2. Duplicate Billing: The practitioner's service may have been billed separately when it should have been included in the facility's charge, leading to a denial as the payer recognizes the service as part of the facility's payment.
3. Misunderstanding of Billing Guidelines: The provider may not be aware that certain services provided in specific settings are not paid separately to practitioners because the payment is encompassed within the facility's reimbursement.
4. Lack of Coordination Between Provider and Facility: There may be a lack of communication or coordination between the billing departments of the practitioner and the facility, resulting in both parties submitting claims for the same service.
5. Incorrect Modifier Usage: The claim might lack the appropriate modifiers that indicate the service is part of the facility's payment, leading to confusion and a subsequent denial.
6. Facility-Based Services: The practitioner may have provided a service that is typically considered a facility-based service, such as certain surgical procedures or diagnostic tests, which are not separately payable to the practitioner in a facility setting.
Addressing these common causes requires careful attention to billing practices, clear communication between providers and facilities, and a thorough understanding of payer guidelines regarding place of service and bundled payments.
Ways to mitigate code M97 include ensuring that billing practices align with the place of service codes that are appropriate for the practitioner's services. It's crucial to verify that the services rendered by the practitioner are billable separately from facility fees when the patient is treated in specific settings. To do this, review the current procedural terminology (CPT) codes and the associated place of service codes before submitting claims.
Additionally, maintain clear communication with the facility to understand their billing practices and to ensure that there is no duplication in billing for the services provided. Regular training for billing staff on the updates regarding place of service requirements and payer-specific guidelines can also help prevent this code from appearing on remittance advice.
The steps to address code M97 involve a review of the claim to ensure that the place of service (POS) was correctly reported. If the POS was inaccurately coded, correct the POS and resubmit the claim. If the POS is correct, but the payment was erroneously denied, contact the payer for clarification. It may be necessary to submit documentation that supports the claim that the service was provided by the practitioner and not included in the facility's reimbursement. If the service was correctly included in the facility's payment, adjust your billing records to reflect the consolidated payment and inform the practitioner of the payment structure for services rendered at that POS.