Remark code N188 indicates that the procedure code submitted on the claim does not align with the level of care that has been authorized or approved by the payer. This discrepancy suggests that the services billed may not be covered or reimbursed as expected because they do not correspond to the pre-determined and agreed-upon level of care for the patient. Healthcare providers should review the claim, verify the accuracy of the procedure codes, and ensure they match the authorized services to resolve this issue and facilitate proper payment.
Common causes of code N188 are discrepancies between the level of care authorized by the payer and the procedure code billed on the claim. This can occur when the healthcare provider submits a claim with a procedure code that is more complex or resource-intensive than the level of care that was pre-authorized for the patient. It may also arise if there is a clerical error in selecting the procedure code, or if there is a misunderstanding about the payer's coverage policies for certain procedures. Additionally, it could be due to a change in the patient's treatment that was not communicated to the payer, resulting in a mismatch when the claim is reviewed against the prior authorization.
Ways to mitigate code N188 include ensuring that the procedure codes submitted on claims accurately reflect the level of care that was approved for the patient. This can be achieved by:
1. Implementing a robust verification process to confirm the approved level of care before services are rendered. This should involve checking the patient's benefits and obtaining prior authorization if necessary.
2. Training staff thoroughly on the latest coding guidelines and payer-specific requirements to ensure that they are selecting the correct procedure codes that correspond with the approved level of care.
3. Utilizing advanced coding software or scrubbing tools that can flag potential mismatches between the level of care and the procedure codes before claims are submitted.
4. Establishing a system of double-checks where a second coder or a coding supervisor reviews claims, especially for high-cost or complex procedures, to ensure accuracy in the level of care and corresponding codes.
5. Keeping up-to-date with changes in coding standards, payer policies, and healthcare regulations to prevent the use of outdated or incorrect codes.
6. Regularly auditing past claims that have received code N188 denials to identify patterns or common errors that can be addressed through staff education or process improvements.
7. Communicating effectively with clinical staff to ensure that documentation clearly supports the level of care provided and matches the procedure codes billed.
8. Developing a feedback loop between the billing department and healthcare providers to discuss and resolve any discrepancies in coding and documentation practices.
By focusing on these strategies, healthcare providers can reduce the likelihood of receiving code N188 denials and improve the accuracy of their claims submissions.
The steps to address code N188 involve a thorough review of the claim to ensure that the procedure code submitted accurately reflects the service provided. If the code is correct, provide additional documentation to support the level of care given. If an error is found, correct the procedure code to match the approved level of care and resubmit the claim. It may also be necessary to contact the payer to clarify the discrepancy and discuss the specifics of the case to determine the appropriate level of care and corresponding procedure code. Regular training for coding staff on updates and changes in coding guidelines can help prevent such discrepancies in the future.