Denial code 118 is related to an adjustment for ESRD (End-Stage Renal Disease) network support. This means that the claim has been denied or adjusted due to issues or discrepancies related to the support provided by the ESRD network.
Common causes of code 118 (ESRD network support adjustment) are:
1. Incomplete or missing documentation: If the healthcare provider fails to provide complete and accurate documentation related to the End-Stage Renal Disease (ESRD) network support, it can result in a denial with code 118.
2. Lack of medical necessity: If the services or treatments provided for ESRD network support are not deemed medically necessary by the payer, it can lead to a denial with code 118. This may occur if the provider fails to provide sufficient evidence or justification for the services rendered.
3. Coding errors: Incorrect coding or billing errors can also trigger a denial with code 118. This can include using the wrong CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes, or failing to include the necessary modifiers.
4. Non-covered services: Some payers may have specific guidelines or limitations on the coverage of ESRD network support services. If the services provided fall outside the scope of the payer's coverage policy, it can result in a denial with code 118.
5. Timely filing limits: Payers often have specific timeframes within which claims must be submitted. If the healthcare provider fails to submit the claim within the designated timeframe, it can result in a denial with code 118.
6. Prior authorization requirements: Certain payers may require prior authorization for ESRD network support services. If the provider fails to obtain the necessary authorization before rendering the services, it can lead to a denial with code 118.
7. Reimbursement policy changes: Payers may periodically update their reimbursement policies, which can impact the coverage and payment for ESRD network support services. If the provider is not aware of or fails to comply with these policy changes, it can result in a denial with code 118.
It is important for healthcare providers to closely review and address these common causes to minimize denials and ensure timely reimbursement for ESRD network support services.
Ways to mitigate code 118 (ESRD network support adjustment) include:
- Ensure accurate documentation: To prevent this code, it is crucial to have complete and accurate documentation of the patient's end-stage renal disease (ESRD) network support. This includes maintaining records of the patient's eligibility, enrollment, and any changes in their network support status.
- Verify patient eligibility: Before providing any services, verify the patient's eligibility for ESRD network support. This can be done by checking their insurance coverage, confirming their enrollment in a network support program, and ensuring that the services provided are covered under their plan.
- Follow proper coding guidelines: Adhere to the correct coding guidelines and use the appropriate codes when submitting claims related to ESRD network support. Familiarize yourself with the specific coding requirements and ensure that the codes accurately reflect the services provided.
- Conduct regular audits: Regularly audit your coding and billing processes to identify any potential errors or discrepancies that may lead to code 118 denials. This can help identify areas for improvement and ensure compliance with coding and billing regulations.
- Stay updated with payer policies: Stay informed about the latest payer policies and guidelines related to ESRD network support. This includes understanding any changes in coverage criteria, documentation requirements, or coding guidelines that may impact the reimbursement process.
- Improve communication with payers: Establish effective communication channels with payers to address any questions or concerns related to ESRD network support. This can help resolve any issues promptly and prevent denials associated with code 118.
- Provide staff training: Ensure that your staff members are well-trained in coding and billing processes specific to ESRD network support. This includes staying updated with the latest coding changes, attending relevant training sessions, and implementing best practices to minimize coding errors.
By implementing these strategies, healthcare providers can mitigate code 118 denials related to ESRD network support and improve their revenue cycle management processes.
The steps to address code 118, ESRD network support adjustment, are as follows:
1. Review the claim details: Carefully examine the claim to ensure that all the necessary information, such as patient demographics, dates of service, and procedure codes, is accurate and complete. Any discrepancies or errors should be corrected promptly.
2. Verify eligibility and coverage: Confirm that the patient is eligible for ESRD network support and that the services provided are covered under their insurance plan. This can be done by contacting the insurance company directly or utilizing online eligibility verification tools.
3. Check for coding errors: Evaluate the coding used on the claim to determine if any errors were made. Ensure that the appropriate diagnosis and procedure codes were used, and that they align with the services rendered. If any coding errors are identified, they should be corrected and resubmitted.
4. Review documentation: Thoroughly review the medical documentation associated with the claim. Ensure that it supports the services billed and provides sufficient justification for the ESRD network support adjustment. If any documentation is missing or incomplete, reach out to the healthcare provider to obtain the necessary information.
5. Appeal if necessary: If the denial is deemed incorrect or unjustified, prepare an appeal to challenge the decision. Gather all relevant documentation, including medical records, coding guidelines, and any additional supporting evidence. Clearly articulate the reasons why the denial should be overturned and submit the appeal within the designated timeframe.
6. Monitor and track: Keep a record of all denials, including code 118, and track the progress of each case. This will help identify any patterns or recurring issues that may require further attention or process improvements. Regularly follow up with the insurance company to ensure that the denial is being addressed and resolved in a timely manner.
By following these steps, healthcare providers can effectively address code 118, ESRD network support adjustment, and work towards resolving the denial to ensure proper reimbursement for the services provided.