Denial code 190 is used when the payment for a service or treatment is already included in the allowance provided for a qualified stay at a Skilled Nursing Facility (SNF). This means that the specific service or treatment is not separately reimbursable as it is already covered within the overall payment for the SNF stay.
Common causes of code 190 are:
1. Inaccurate billing: The healthcare provider may have incorrectly billed for services that are already included in the payment allowance for a Skilled Nursing Facility (SNF) qualified stay. This could be due to a misunderstanding of the billing guidelines or a failure to properly document and code the services provided.
2. Lack of supporting documentation: The healthcare provider may not have provided sufficient documentation to justify the services billed for a SNF qualified stay. Without proper documentation, the payer may deny the claim and assign code 190.
3. Missing or incomplete information: The claim may be missing important information or have incomplete details related to the SNF qualified stay. This could include missing patient information, dates of service, or other required fields. Such missing or incomplete information can lead to a denial with code 190.
4. Non-covered services: The services billed may not be covered under the SNF qualified stay benefit. It is essential for healthcare providers to understand the specific services that are included in the payment allowance for a SNF qualified stay and ensure that only eligible services are billed.
5. Coding errors: Errors in coding can also result in denials with code 190. This could include using incorrect procedure codes, diagnosis codes, or modifiers. It is crucial for healthcare providers to accurately code the services provided to avoid denials related to coding errors.
6. Prior authorization requirements: Some payers may require prior authorization for certain services related to a SNF qualified stay. If the healthcare provider fails to obtain the necessary prior authorization, the claim may be denied with code 190.
7. Timely filing limits: If the claim is not submitted within the specified timeframe set by the payer, it may be denied with code 190. Healthcare providers should be aware of the timely filing limits and ensure that claims are submitted in a timely manner.
It is important for healthcare providers to address these common causes of code 190 to minimize claim denials and optimize their revenue cycle management.
Ways to mitigate code 190 include:
- Accurate documentation: Ensure that all documentation related to the patient's stay at a Skilled Nursing Facility (SNF) is complete and accurate. This includes the admission and discharge dates, as well as any relevant medical records and treatment plans. By maintaining thorough and precise documentation, you can provide the necessary evidence to support the claim and prevent denials.
- Eligibility verification: Before admitting a patient to a SNF, verify their eligibility for the stay. This involves confirming that the patient meets the criteria set by the payer, such as requiring skilled nursing care or meeting the minimum length of stay requirements. By conducting eligibility verification upfront, you can identify any potential issues that may lead to denials and address them proactively.
- Utilization review: Conduct regular utilization reviews to assess the medical necessity and appropriateness of the patient's stay at the SNF. This involves evaluating the patient's condition, treatment plan, and progress to ensure that they still require skilled nursing care. By regularly reviewing the patient's status, you can identify any changes that may impact the payment and address them promptly.
- Clear communication: Maintain open and clear communication channels with the SNF staff, ensuring that they understand the payer's requirements and guidelines. This includes providing education and training on coding and billing practices specific to SNF stays. By fostering effective communication, you can minimize errors and misunderstandings that may lead to denials.
- Continuous staff education: Stay updated with the latest coding and billing regulations related to SNF stays. Provide ongoing education and training to your staff to ensure they are aware of any changes and can accurately code and bill for services provided. By investing in staff education, you can reduce the risk of coding errors and denials.
- Regular audits: Conduct regular internal audits to identify any potential coding or billing errors related to SNF stays. This involves reviewing claims, documentation, and coding practices to ensure compliance with payer guidelines. By proactively identifying and addressing any issues, you can prevent denials and optimize revenue.
Remember, these strategies are general recommendations, and it's important to consult with your specific payer guidelines and policies to ensure compliance and maximize reimbursement.
The steps to address code 190 are as follows:
- Review the patient's medical records and billing documentation to ensure that the services provided were indeed related to a Skilled Nursing Facility (SNF) qualified stay. This includes verifying the dates of the stay and the services rendered during that time.
- Check the insurance policy or contract to determine if the payment for SNF services is indeed included in the allowance. Look for any specific guidelines or limitations regarding SNF stays and payments.
- If the documentation and policy confirm that the payment should be included in the allowance, ensure that the claim was submitted correctly with the appropriate codes and modifiers. Double-check for any errors or omissions that may have led to the denial.
- If there are any discrepancies or issues with the claim, reach out to the insurance company or payer for clarification. Provide any necessary supporting documentation to support your case and explain why the payment should be included in the allowance.
- If the denial persists despite your efforts, consider appealing the decision. Prepare a strong and well-documented appeal letter that outlines the reasons why the payment should be included in the allowance. Include any relevant medical records, policy information, and supporting documentation to strengthen your case.
- Monitor the progress of the appeal and follow up with the insurance company or payer regularly to ensure that it is being reviewed and processed in a timely manner.
- If the appeal is successful, ensure that the payment is correctly processed and applied to the patient's account. Update the billing records and any necessary documentation to reflect the approved payment.
By following these steps, healthcare providers can effectively address code 190 and work towards resolving the denial and obtaining the appropriate payment for SNF services.