Denial code 186 is related to a level of care change adjustment. This means that the claim has been denied because there was a change in the level of care provided to the patient. It could indicate that the services rendered were not consistent with the level of care initially authorized or requested.
Common causes of code 186, which indicates a level of care change adjustment, are:
1. Inadequate documentation: Insufficient or incomplete documentation of the patient's condition and the need for a change in level of care can result in a denial. This may include missing or incomplete progress notes, lack of supporting medical records, or failure to provide necessary details about the patient's condition.
2. Lack of medical necessity: If the level of care change is not deemed medically necessary by the payer, it can lead to a denial. Payers typically require clear evidence that the change in level of care is justified based on the patient's condition and treatment needs.
3. Incorrect coding: Errors in coding, such as using an incorrect procedure or diagnosis code, can result in a denial. It is important to ensure accurate and appropriate coding that aligns with the patient's condition and the services provided.
4. Failure to meet criteria: Payers often have specific criteria that must be met for a level of care change to be approved. If the healthcare provider fails to meet these criteria or does not provide sufficient evidence to support the change, it can lead to a denial.
5. Lack of pre-authorization: Some payers require pre-authorization for a level of care change. If the healthcare provider fails to obtain the necessary pre-authorization or does not follow the payer's guidelines for obtaining it, it can result in a denial.
6. Billing errors: Mistakes in the billing process, such as incorrect patient information, missing or incorrect insurance details, or failure to submit the claim within the specified timeframe, can lead to a denial of the level of care change adjustment.
7. Insufficient supporting documentation: Along with inadequate documentation, the lack of supporting documentation to justify the level of care change can also result in a denial. This may include failure to provide relevant test results, consultation notes, or other necessary documentation.
8. Lack of communication: Poor communication between the healthcare provider and the payer can lead to denials. This may include failure to provide requested information or clarification, not responding to payer inquiries in a timely manner, or not following up on any additional documentation or requirements requested by the payer.
It is important for healthcare providers to address these common causes and take necessary steps to prevent denials related to code 186. This may involve improving documentation practices, ensuring medical necessity is clearly demonstrated, conducting regular coding audits, obtaining pre-authorization when required, and maintaining effective communication with payers.
Ways to mitigate code 186, which indicates a level of care change adjustment, include:
- Accurate documentation: Ensure that all patient records accurately reflect the level of care provided. This includes documenting any changes in the patient's condition that may warrant a level of care change.
- Effective communication: Foster open lines of communication between healthcare providers, case managers, and billing staff. This will help ensure that any level of care changes are promptly communicated and accurately reflected in the billing process.
- Utilize standardized protocols: Implement standardized protocols for level of care changes to ensure consistency and compliance with payer requirements. This can help reduce the likelihood of denials related to incorrect or inconsistent coding.
- Regular staff training: Provide ongoing training to coding and billing staff to ensure they are up-to-date with the latest coding guidelines and payer requirements. This will help minimize errors and improve accuracy in coding for level of care changes.
- Conduct regular audits: Perform regular internal audits to identify any coding or documentation gaps related to level of care changes. This proactive approach can help identify and address any issues before they result in denials.
- Utilize technology solutions: Implement technology solutions, such as automated coding and billing software, that can help streamline the coding process and reduce the risk of errors. These tools can also provide real-time alerts and reminders for level of care changes, ensuring timely and accurate billing.
By implementing these strategies, healthcare providers can mitigate code 186 denials and improve their revenue cycle management processes.
The steps to address code 186, Level of care change adjustment, are as follows:
1. Review the patient's medical records: Carefully examine the patient's medical records to understand the reason for the level of care change. Look for any documentation that supports the need for the change in care level.
2. Verify the accuracy of the coding: Double-check the coding used for the level of care change. Ensure that the appropriate codes are assigned based on the patient's condition and the services provided.
3. Gather supporting documentation: Collect any additional documentation that may be required to support the level of care change. This could include progress notes, test results, or any other relevant information that justifies the change in care level.
4. Prepare an appeal letter: Write a concise and persuasive appeal letter explaining the reasons for the level of care change. Clearly articulate the medical necessity and provide supporting evidence from the patient's medical records.
5. Submit the appeal: Follow the specific guidelines provided by the payer for submitting appeals. Make sure to include all the necessary documentation and any other required forms or information.
6. Monitor the status of the appeal: Keep track of the appeal's progress and any communication from the payer. Follow up regularly to ensure that the appeal is being processed and reviewed in a timely manner.
7. Consider escalation options: If the appeal is denied or not resolved satisfactorily, explore further escalation options. This may involve contacting a supervisor or manager at the payer's organization or seeking assistance from a healthcare revenue cycle management expert.
Remember, each code may have unique requirements and considerations. It is essential to thoroughly understand the specific denial code and follow the appropriate steps to address it effectively.