Remark code N65 indicates that the procedure code billed or the number of times the procedure was performed (procedure rate count) cannot be verified or was not recognized in the payer's system for the date of service provided. This could mean that the code was not entered correctly, is not valid for the date of service, or does not match the provider's records. It may require the provider to review the coding and billing information submitted and possibly resubmit the claim with the correct information.
Common causes of code N65 are:
1. The procedure code submitted is not recognized by the payer's claims processing system for the date of service provided.
2. The procedure code is either incorrect or has been entered with a typographical error.
3. The rate count for the procedure, which determines the unit of service, is missing or has not been properly reported.
4. The procedure code may be new or updated, and the payer's system has not yet been updated to include it.
5. The provider's contract with the payer may not include the submitted procedure code, making it non-reimbursable for that specific date of service.
6. The claim was submitted with outdated or invalid coding, possibly due to changes in coding standards (e.g., transition from ICD-9 to ICD-10).
7. The procedure code may require additional documentation or authorization that was not provided with the claim.
8. The claim form may have been incomplete or improperly formatted, leading to the rejection of the procedure code information.
Ways to mitigate code N65 include ensuring that the procedure codes are current, valid, and appropriate for the date of service before submitting the claim. Regularly updating the practice's charge master to reflect the latest Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes can prevent outdated or incorrect codes from being used. Additionally, verifying that the procedure codes match the services provided and are within the scope of the provider's credentials is crucial. Implementing a pre-claim adjudication process that includes code validation checks can also help catch errors before submission. Training staff on proper coding techniques and staying informed about coding updates and payer-specific guidelines will further reduce the likelihood of receiving an N65 remark code.
The steps to address code N65 involve a multi-faceted approach to ensure accurate billing and reimbursement. First, verify the procedure code against the most current coding resources, such as the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) manuals, to confirm that it is valid for the date of service. If the code is outdated or incorrect, correct it in the billing system and resubmit the claim.
Next, review the provider's contract and fee schedule to ensure the procedure is covered and the rate count is accurate. If the procedure is not listed or the rate is incorrect, update the fee schedule or negotiate with the payer as necessary.
Additionally, check the claim form for any errors in the date of service or provider information that could have led to the denial. Correct any discrepancies and resubmit the claim.
If the procedure code and rate count are correct and on file, but the claim is still denied, contact the payer directly for clarification. Provide them with documentation, such as operative reports or medical records, to support the claim and request a re-evaluation of the denial.
Finally, document all steps taken to resolve the issue for future reference and to support any potential appeals. This documentation will be crucial if the payer continues to deny the claim despite the corrective actions taken.