Denial code 248 means that the coinsurance for a professional service was rendered in an institutional setting and billed on an institutional claim. In other words, it indicates that the insurance company is denying the claim because the coinsurance amount for a service provided by a healthcare professional in a hospital or other institutional setting was billed incorrectly on a claim that should have been submitted as an institutional claim.
Common causes of code 248 are:
1. Incorrect billing: One of the most common causes of code 248 is incorrect billing. This can occur when a professional service rendered in an institutional setting is billed on an institutional claim instead of a professional claim. It is important to ensure that the correct claim type is used to avoid this denial code.
2. Lack of documentation: Insufficient or incomplete documentation can also lead to code 248 denials. If the necessary documentation to support the professional service rendered in an institutional setting is not provided, the claim may be denied with this code.
3. Coding errors: Coding errors, such as using the wrong procedure or diagnosis codes, can result in code 248 denials. It is crucial to accurately assign the appropriate codes to ensure proper reimbursement and avoid denials.
4. Coordination of benefits issues: Code 248 may also be triggered due to coordination of benefits issues. If the patient has another insurance plan that should be primary for the professional service rendered in an institutional setting, but it was not properly coordinated, the claim may be denied with this code.
5. Lack of pre-authorization: Some insurance plans require pre-authorization for certain services. If the professional service rendered in an institutional setting was not pre-authorized when required, it can result in a denial with code 248.
6. Out-of-network providers: If the healthcare provider is out-of-network for the patient's insurance plan, it can lead to code 248 denials. It is important to verify the provider's network status before rendering services to avoid potential denials.
7. Timely filing limits: Insurance companies have specific timeframes within which claims must be submitted. Failure to submit the claim within the specified timeframe can result in denials, including code 248.
8. Policy exclusions: Some insurance plans may have specific policy exclusions for certain services or settings. If the professional service rendered in an institutional setting falls under a policy exclusion, it can lead to denials with code 248.
It is important for healthcare providers to address these common causes of code 248 denials to improve their revenue cycle management and ensure timely and accurate reimbursement.
Ways to mitigate code 248 include:
- Accurate documentation: Ensure that all professional services rendered in an institutional setting are properly documented. This includes documenting the specific services provided, the date and time of service, and any relevant patient information. Accurate and detailed documentation can help prevent denials related to incorrect coding or billing.
- Clear communication: Foster effective communication between the healthcare provider and the billing department. It is crucial to ensure that the billing department is aware of any professional services rendered in an institutional setting. This will help them accurately code and bill these services, reducing the likelihood of denials.
- Staff training: Provide comprehensive training to the billing and coding staff on the specific requirements and guidelines for billing professional services rendered in an institutional setting. This will help them understand the nuances of coding and billing for these services, minimizing the risk of denials.
- Regular audits: Conduct regular audits of coding and billing processes to identify any potential errors or issues related to professional services rendered in an institutional setting. By proactively identifying and addressing these issues, you can prevent denials and ensure accurate reimbursement.
- Utilize technology: Implement advanced billing software or revenue cycle management systems that have built-in checks and balances to catch any coding or billing errors related to professional services rendered in an institutional setting. These systems can help automate the coding and billing process, reducing the risk of denials.
- Stay updated with payer policies: Stay informed about the specific payer policies and guidelines related to professional services rendered in an institutional setting. Regularly review and update your billing practices to align with these policies, ensuring compliance and reducing the likelihood of denials.
By implementing these strategies, healthcare providers can mitigate code 248 and minimize denials related to coinsurance for professional services rendered in an institutional setting and billed on an institutional claim.
The steps to address code 248 are as follows:
- Review the claim: Carefully examine the claim to ensure that the professional service was indeed rendered in an institutional setting and billed on an institutional claim. Verify that all the necessary information, such as the patient's demographic details, service dates, and provider information, are accurate and complete.
- Check for coding errors: Double-check the coding used for the service provided. Ensure that the appropriate codes were used to accurately represent the service rendered. Look for any potential coding errors or discrepancies that may have led to the code 248 denial.
- Verify insurance coverage: Confirm that the patient's insurance coverage includes coinsurance for professional services rendered in an institutional setting. Review the patient's insurance policy or contact the insurance company directly to ensure that the claim is eligible for coinsurance reimbursement.
- Appeal the denial: If you believe that the denial is incorrect or unjustified, consider appealing the denial. Prepare a strong and well-documented appeal letter that clearly explains why the denial should be overturned. Provide any supporting documentation, such as medical records or additional coding information, to strengthen your case.
- Educate staff and providers: If code 248 denials are a recurring issue, it may be necessary to educate your staff and providers on the correct billing procedures for professional services rendered in an institutional setting. Conduct training sessions or provide resources that outline the proper coding and billing guidelines to minimize future denials.
- Monitor and track denials: Keep a record of all code 248 denials and track the trends and patterns. Analyze the root causes of these denials to identify any systemic issues that need to be addressed. Implement corrective measures to prevent future denials and improve the overall revenue cycle management process.
By following these steps, healthcare providers can effectively address code 248 denials and optimize their revenue cycle management.