Denial code 173 is used when a service or equipment is not prescribed by a physician. This means that the healthcare provider has submitted a claim for a service or equipment that was not ordered or authorized by a physician, resulting in the denial of the claim by the insurance company.
Common causes of code 173 are:
1. Lack of proper documentation: The service or equipment in question may not have been prescribed by a physician due to a lack of proper documentation. This could include missing or incomplete medical records, illegible handwriting, or failure to include necessary information such as diagnosis codes or medical necessity.
2. Non-compliance with medical guidelines: The service or equipment may not meet the medical guidelines or criteria set by insurance payers or regulatory bodies. This could be due to the service or equipment being considered experimental or investigational, not meeting the necessary criteria for coverage, or not being deemed medically necessary for the patient's condition.
3. Lack of prior authorization: Some insurance plans require prior authorization for certain services or equipment. If the provider did not obtain the necessary authorization before providing the service or equipment, it may result in a denial with code 173.
4. Incorrect coding or billing: Errors in coding or billing can also lead to denials with code 173. This could include using the wrong procedure or diagnosis codes, billing for services or equipment that were not actually provided, or submitting claims with incorrect or incomplete information.
5. Insufficient medical necessity documentation: Insurance payers often require detailed documentation to support the medical necessity of a service or equipment. If the provider fails to provide sufficient documentation to justify the need for the service or equipment, it may result in a denial with code 173.
6. Lack of coverage: In some cases, the service or equipment may simply not be covered by the patient's insurance plan. This could be due to exclusions or limitations in the policy, or the service or equipment not being considered medically necessary for the patient's condition.
It is important for healthcare providers to address these common causes of code 173 to minimize denials and ensure proper reimbursement for services and equipment provided. This can be achieved through thorough documentation, adherence to medical guidelines, obtaining necessary prior authorizations, accurate coding and billing, and ensuring the medical necessity of the service or equipment is well-documented.
Ways to mitigate code 173 include:
- Ensure proper documentation: To prevent this denial code, it is crucial to have accurate and detailed documentation that clearly indicates the medical necessity for the service or equipment. This includes documenting the physician's prescription or order for the specific service or equipment.
- Improve communication with physicians: Establish a strong line of communication with physicians to ensure that they are aware of the necessary documentation requirements. Regularly educate and remind them about the importance of prescribing services and equipment in accordance with the payer's guidelines.
- Implement pre-authorization processes: Prior to providing any service or equipment, implement a pre-authorization process to verify that the service or equipment is medically necessary and prescribed by a physician. This will help identify any potential issues before the claim is submitted, reducing the chances of a denial.
- Train staff on coding guidelines: Provide comprehensive training to coding and billing staff to ensure they are well-versed in the payer's coding guidelines. This will help them accurately assign the appropriate codes and ensure that services and equipment are properly documented and prescribed.
- Conduct regular audits: Perform regular internal audits to identify any potential issues or gaps in documentation. This will help identify areas for improvement and allow for corrective actions to be taken proactively.
- Stay updated with payer policies: Stay informed about the latest payer policies and guidelines regarding the prescription of services and equipment. Regularly review and update internal processes to align with these policies, reducing the risk of denials related to code 173.
- Utilize technology solutions: Implement technology solutions such as electronic health record (EHR) systems or revenue cycle management (RCM) software that can help streamline documentation processes and ensure that all necessary information is captured accurately.
By implementing these strategies, healthcare providers can mitigate denial code 173 and improve their revenue cycle management processes.
The steps to address code 173 (Service/equipment was not prescribed by a physician) are as follows:
1. Review the claim documentation: Carefully examine the claim documentation to ensure that all necessary information is included. Check if the service or equipment in question was indeed not prescribed by a physician.
2. Verify the ordering provider: Confirm the identity and credentials of the ordering provider. Ensure that they are a licensed physician or other qualified healthcare professional authorized to prescribe the specific service or equipment.
3. Communicate with the ordering provider: Reach out to the ordering provider to discuss the denial code and gather additional information. Seek clarification on whether the service or equipment was actually prescribed and if there was any oversight or error in the documentation.
4. Obtain supporting documentation: If the service or equipment was indeed prescribed by a physician, gather all relevant supporting documentation. This may include the original prescription, medical records, progress notes, or any other evidence that validates the medical necessity of the service or equipment.
5. Submit an appeal or corrected claim: Based on the information gathered, submit an appeal or corrected claim to the payer. Include all necessary documentation and a clear explanation of why the denial code is incorrect or should be reconsidered.
6. Follow up with the payer: Keep track of the appeal or corrected claim and follow up with the payer to ensure it is being processed. Stay in communication with the payer's representative to address any questions or concerns they may have.
7. Monitor and track denials: Continuously monitor and track denial trends, including code 173, to identify any patterns or recurring issues. This will help in implementing proactive measures to prevent similar denials in the future.
Remember, it is crucial to thoroughly understand the specific denial code and its implications to effectively address it. By following these steps, healthcare providers can improve their chances of successfully resolving denial code 173 and ensuring appropriate reimbursement for services and equipment provided.