Remark code N170 indicates that the payer requires a new, revised, or renewed Certificate of Medical Necessity (CMN) for the claim to be processed. This documentation must be provided by the healthcare provider to certify that the services or equipment billed are medically necessary for the patient.
Common causes of code N170 are:
1. The initial certificate of medical necessity (CMN) has expired, and a new one is required for continued service or billing.
2. The information on the current CMN is outdated due to a change in the patient's medical condition, requiring an updated document.
3. The CMN on file is incomplete or lacks the necessary detail to justify the medical necessity of the services or equipment billed.
4. The CMN was not received or is missing from the patient's file, and a valid copy needs to be submitted to process the claim.
5. There has been a renewal of the patient's treatment plan or prescription, necessitating a revised CMN to reflect the current therapy or equipment needs.
6. The payer's requirements for CMN renewal frequency have not been met, and a new CMN is due based on the payer's specific timelines or regulations.
7. The submitted CMN does not match the billed services or diagnosis codes, indicating a discrepancy that must be corrected with a new or revised CMN.
8. The CMN lacks the required physician's signature or credentials, making it invalid and requiring a properly executed replacement.
Ways to mitigate code N170 include implementing a system to track expiration dates of current certificates of medical necessity (CMNs) and setting up alerts for renewals. Regularly training staff on the documentation requirements for CMNs can ensure that they are completed accurately and fully at the time of patient evaluation or equipment delivery. Additionally, establishing a protocol for regular communication with physicians can facilitate timely receipt of new, revised, or renewed CMNs. Automating the submission and retrieval process of CMNs through an electronic health record (EHR) system can also help streamline the process and reduce the likelihood of this code being triggered.
The steps to address code N170 involve several key actions to ensure that the necessary documentation is updated and submitted correctly. First, review the patient's medical records to confirm that a certificate of medical necessity (CMN) is indeed required for the services billed. Next, contact the patient's healthcare provider to obtain a new, revised, or renewed CMN. Ensure that the CMN is fully completed, with all required signatures and dates, and that it includes the appropriate medical justification for the services or equipment provided.
Once the updated CMN is in hand, re-submit the claim with the attached CMN to the payer. It's important to check that all other aspects of the claim are accurate and meet the payer's requirements to avoid further denials. Keep a copy of the submitted CMN on file for future reference and follow up with the payer to confirm receipt and processing of the updated documentation. If the claim is denied again, review the explanation of benefits (EOB) for any additional information provided and take the necessary corrective action.