Denial code 189 means that a procedure or service was billed using a "not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) when there is a specific procedure code available for that particular procedure or service. In other words, the code used for billing does not match a more specific code that should have been used instead.
Common causes of code 189 are:
1. Lack of specificity: The healthcare provider may have billed a generic "not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) instead of using a specific procedure code that accurately describes the procedure or service provided. This can lead to a denial as payers require specific codes for accurate billing and reimbursement.
2. Inadequate documentation: Insufficient documentation supporting the need for the procedure or service can result in a denial with code 189. Payers require detailed documentation that justifies the use of a specific procedure code, and if the documentation is lacking or incomplete, the claim may be denied.
3. Coding errors: Human errors in coding can also lead to the use of code 189. This can occur when the coder is not familiar with the specific procedure code or when there is confusion regarding the appropriate code to use. Such errors can result in denials and delays in reimbursement.
4. Failure to update coding guidelines: Healthcare providers need to stay updated with the latest coding guidelines and changes to ensure accurate billing. If the provider fails to update their coding practices and continues to use outdated or incorrect codes, it can result in denials with code 189.
5. Lack of medical necessity: Payers require that procedures or services billed are medically necessary and meet specific criteria. If the healthcare provider fails to demonstrate medical necessity for the procedure or service, it can result in a denial with code 189.
6. Unbundling of services: Unbundling refers to billing separate procedure codes for components of a bundled service. If the healthcare provider incorrectly bills individual components instead of using the appropriate bundled code, it can result in a denial with code 189.
7. Non-covered services: Some procedures or services may not be covered by the payer's policy. If the healthcare provider bills for a non-covered service using code 189, it will result in a denial.
It is important for healthcare providers to review their coding practices, ensure accurate documentation, stay updated with coding guidelines, and verify medical necessity to avoid denials with code 189 and optimize their revenue cycle management.
Ways to mitigate code 189 include:
- Conduct thorough documentation: Ensure that all procedures and services are accurately documented with specific procedure codes. Avoid using "not otherwise classified" or "unlisted" codes unless there is no specific code available.
- Stay updated with coding guidelines: Regularly review and stay updated with the latest coding guidelines provided by relevant authorities such as the American Medical Association (AMA) or Centers for Medicare and Medicaid Services (CMS). This will help you identify the appropriate procedure code for each service.
- Utilize coding resources: Take advantage of coding resources such as coding books, online coding databases, or software tools that provide comprehensive code sets and descriptions. These resources can help you find the specific procedure code that accurately represents the service provided.
- Train coding staff: Ensure that your coding staff receives regular training and education on coding guidelines and updates. This will help them understand the importance of using specific procedure codes and avoid billing "not otherwise classified" or "unlisted" codes unnecessarily.
- Implement coding audits: Conduct regular coding audits to identify any instances where "not otherwise classified" or "unlisted" codes are being used inappropriately. Address any coding errors or knowledge gaps through additional training and education.
- Collaborate with healthcare professionals: Foster open communication and collaboration between coding staff, physicians, and other healthcare professionals. Encourage them to provide detailed documentation and specific procedure information to ensure accurate coding.
- Utilize coding software with built-in alerts: Consider using coding software that includes built-in alerts or prompts to help identify when a specific procedure code should be used instead of a "not otherwise classified" or "unlisted" code. These alerts can serve as a helpful reminder for accurate coding.
By implementing these strategies, healthcare providers can reduce the occurrence of code 189 and ensure that specific procedure codes are used appropriately, leading to fewer claim denials and improved revenue cycle management.
The steps to address code 189 are as follows:
- Review the billed procedure/service: Carefully examine the procedure or service that was billed using the "not otherwise classified" or "unlisted" procedure code (CPT/HCPCS). Ensure that there is not a specific procedure code available for this particular service.
- Verify the documentation: Check the medical documentation associated with the billed procedure/service. Ensure that it clearly supports the need for using the "not otherwise classified" or "unlisted" code. Look for any specific details or circumstances that justify the use of this code.
- Consult coding guidelines: Refer to the official coding guidelines provided by the American Medical Association (AMA) or the Centers for Medicare and Medicaid Services (CMS). These guidelines offer instructions on when it is appropriate to use "not otherwise classified" or "unlisted" codes. Compare the documentation with the guidelines to determine if the use of this code is justified.
- Consider alternative codes: If there is a specific procedure code available for the service provided, consider whether it would be more appropriate to use that code instead. Evaluate if the documentation supports the use of the specific code and if it accurately reflects the service rendered.
- Communicate with the billing/coding team: Reach out to the billing or coding team responsible for submitting the claim. Discuss the code in question and provide any additional documentation or information that supports the use of the "not otherwise classified" or "unlisted" code. Collaborate with the team to ensure accurate coding and billing practices.
- Appeal if necessary: If the use of the "not otherwise classified" or "unlisted" code is justified based on the documentation and coding guidelines, but the claim is still denied, consider appealing the denial. Provide a detailed explanation of why the code was used and include any supporting documentation to strengthen the appeal.
By following these steps, healthcare providers can effectively address code 189 and ensure accurate coding and billing practices.