Denial code 175 is used when a prescription submitted for reimbursement is considered incomplete. This means that the prescription does not contain all the necessary information required for processing, such as the patient's name, dosage instructions, or medication details. As a result, the claim is denied, and the healthcare provider will need to resubmit a complete prescription for reimbursement.
Common causes of code 175 are:
- Missing or incomplete patient information: The prescription may be missing essential patient details such as name, date of birth, or contact information. Incomplete patient information can lead to denials as it hinders the proper identification and verification of the patient.
- Inaccurate or missing medication details: The prescription may lack crucial information about the prescribed medication, such as the name, dosage, frequency, or duration. Inaccurate or missing medication details can result in denials as it becomes challenging for the payer to determine the appropriateness and necessity of the prescribed medication.
- Lack of physician signature: A prescription without a valid physician signature is considered incomplete. The absence of a physician's signature raises concerns about the authenticity and validity of the prescription, leading to denials.
- Illegible handwriting: If the prescription is difficult to read due to illegible handwriting, it can result in denials. Illegible prescriptions can lead to errors in medication administration and pose risks to patient safety.
- Missing supporting documentation: Some prescriptions require additional supporting documentation, such as prior authorization or medical necessity documentation. If the necessary supporting documents are missing, the claim may be denied.
- Non-compliance with formulary requirements: Health insurance plans often have formularies that outline the preferred medications and their coverage. If the prescribed medication does not comply with the formulary requirements, the claim may be denied.
- Incorrect coding or billing: If the prescription is coded or billed incorrectly, it can lead to denials. This includes errors in assigning the appropriate diagnosis or procedure codes, as well as incorrect billing of the medication or service.
- Exceeding quantity limits: Some medications have quantity limits imposed by insurance plans. If the prescribed quantity exceeds the allowed limit, the claim may be denied.
- Lack of medical necessity: Payers may deny claims if they deem the prescribed medication or service as not medically necessary. This can occur if the documentation does not adequately support the medical need for the prescribed treatment.
- Expired or invalid prescription: If the prescription has expired or is no longer valid, it will be denied. It is essential to ensure that prescriptions are current and within the specified validity period.
It is crucial for healthcare providers to address these common causes to minimize claim denials and ensure timely reimbursement for their services.
Ways to mitigate code 175 (Prescription is incomplete) include:
- Ensure accurate and complete documentation: Providers should ensure that all necessary information is included in the prescription, such as the patient's name, date of birth, medication name, dosage, frequency, and duration. Double-checking the prescription for any missing or incomplete information can help prevent denials related to code 175.
- Implement standardized prescription templates: Using standardized prescription templates can help ensure that all required information is consistently included. These templates can be customized to include specific fields for different types of medications or treatments, reducing the chances of incomplete prescriptions.
- Provide clear instructions to prescribing physicians: It is essential to communicate with the prescribing physicians and educate them about the importance of providing complete prescriptions. This can be done through regular meetings, training sessions, or even sending out reminders highlighting the common errors that lead to incomplete prescriptions.
- Utilize electronic prescribing systems: Electronic prescribing systems can help reduce the chances of incomplete prescriptions by providing prompts and reminders for required information. These systems can also flag any missing or incorrect information before the prescription is finalized, allowing for immediate correction.
- Conduct regular audits and quality checks: Implementing a system of regular audits and quality checks can help identify any patterns or recurring issues related to incomplete prescriptions. By analyzing these findings, providers can develop targeted interventions and provide additional training or resources to address the root causes of incomplete prescriptions.
- Collaborate with pharmacists and pharmacy staff: Maintaining open lines of communication with pharmacists and pharmacy staff can help identify any issues or challenges related to incomplete prescriptions. By working together, providers and pharmacists can develop strategies to improve the prescription process and reduce denials associated with code 175.
By implementing these strategies, healthcare providers can proactively mitigate code 175 and minimize denials related to incomplete prescriptions, ultimately improving the revenue cycle management process.
The steps to address code 175, which indicates that the prescription is incomplete, are as follows:
- Review the denied claim: Carefully examine the denied claim to identify the specific prescription that is incomplete. Look for any missing information or documentation that may have led to the denial.
- Contact the prescribing physician: Reach out to the prescribing physician to clarify any missing or incomplete information. Request the necessary details to complete the prescription, such as dosage, frequency, or duration of the medication.
- Update the prescription: Once you have obtained the missing information from the prescribing physician, update the prescription accordingly. Ensure that all required fields are completed accurately and legibly.
- Resubmit the claim: After updating the prescription, resubmit the claim to the appropriate payer. Double-check that all other information on the claim is accurate and up-to-date.
- Document the communication: Keep a record of all communication with the prescribing physician regarding the incomplete prescription. This documentation will be useful for future reference and potential audits.
- Monitor the claim status: Track the status of the resubmitted claim to ensure that it is processed correctly. If the claim is still denied or if any further issues arise, follow up with the payer to address the situation promptly.
By following these steps, healthcare providers can effectively address code 175 and ensure that the prescription is complete, increasing the chances of successful claim reimbursement.