Denial code 55 is used when a procedure, treatment, or drug is considered experimental or investigational by the payer. This means that the payer does not consider the specific procedure, treatment, or drug to be proven or established as effective for the patient's condition. To get more information about this denial code, you can refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if it is present in the denial information.
Common causes of code 55 are:
1. Procedure or treatment is considered experimental or investigational by the payer: This denial code indicates that the payer does not consider the procedure or treatment to be medically necessary or proven effective. It may be based on the payer's own policies or guidelines.
2. Lack of supporting documentation: The denial may occur if the healthcare provider fails to provide sufficient documentation to justify the medical necessity of the procedure or treatment. This could include clinical notes, test results, or other relevant information.
3. Inadequate pre-authorization or prior approval: Some payers require pre-authorization or prior approval for certain procedures or treatments. If the provider did not obtain the necessary authorization before performing the service, it can result in a denial with code 55.
4. Non-covered service: The procedure or treatment may not be covered under the patient's insurance plan. This could be due to specific plan exclusions or limitations, such as cosmetic procedures or experimental treatments.
5. Coding errors: Incorrect coding or billing can lead to denials. If the procedure or treatment is not coded correctly or if there are discrepancies between the billed services and the supporting documentation, it can result in a denial with code 55.
6. Lack of medical necessity: Even if a procedure or treatment is generally considered medically necessary, it may be denied if the payer determines that it is not necessary in the specific case. This could be due to factors such as the patient's condition, alternative treatment options, or lack of supporting evidence.
It is important for healthcare providers to review denial code 55 and address the specific cause in order to appeal the denial or prevent similar denials in the future.
Ways to mitigate code 55 include:
- Conduct thorough research: Stay updated with the latest medical advancements and guidelines to ensure that the procedures, treatments, or drugs being billed are not considered experimental or investigational by payers. This will help you avoid potential denials based on code 55.
- Provide supporting documentation: When submitting claims, include detailed documentation that clearly demonstrates the medical necessity and effectiveness of the procedure, treatment, or drug being billed. This can include relevant research studies, clinical trials, or expert opinions that support its use.
- Communicate with payers: Establish open lines of communication with payers to understand their specific criteria for determining whether a procedure, treatment, or drug is considered experimental or investigational. This will help you align your billing practices accordingly and reduce the risk of denials based on code 55.
- Utilize prior authorization: Before performing any procedure or administering a treatment or drug, obtain prior authorization from the payer. This ensures that the payer has reviewed and approved the medical necessity of the service, reducing the likelihood of denials based on experimental or investigational status.
- Stay informed about payer policies: Regularly review and familiarize yourself with the policies and guidelines of different payers regarding experimental or investigational procedures, treatments, or drugs. This will help you proactively identify any potential conflicts and adjust your billing practices accordingly.
- Collaborate with healthcare professionals: Engage in discussions and collaborations with other healthcare professionals, such as specialists or researchers, to gain insights into the latest evidence-based practices and treatments. This can help you ensure that the services you provide are widely accepted and supported by the medical community, reducing the risk of denials based on code 55.
- Appeal denied claims: If a claim is denied based on code 55, promptly initiate the appeals process. Provide additional supporting documentation and any relevant information that demonstrates the medical necessity and effectiveness of the procedure, treatment, or drug. This can increase the chances of overturning the denial and receiving reimbursement.
By implementing these strategies, healthcare providers can mitigate code 55 and minimize denials related to procedures, treatments, or drugs being deemed experimental or investigational by payers.
The steps to address code 55, which indicates that the procedure/treatment/drug is deemed experimental/investigational by the payer, are as follows:
1. Review the documentation: Carefully review the medical records and documentation related to the procedure, treatment, or drug in question. Ensure that the documentation clearly supports the medical necessity and justifies the use of the procedure, treatment, or drug.
2. Gather supporting evidence: Collect any additional supporting evidence that can help substantiate the medical necessity of the procedure, treatment, or drug. This may include research studies, clinical guidelines, expert opinions, or any other relevant documentation that demonstrates the effectiveness or appropriateness of the procedure, treatment, or drug.
3. Consult with the healthcare provider: Engage in discussions with the healthcare provider who performed or prescribed the procedure, treatment, or drug. Seek their input and expertise to understand the rationale behind the use of the procedure, treatment, or drug and gather any additional information that can support the claim.
4. Prepare an appeal letter: Based on the gathered documentation and discussions, draft a well-structured and persuasive appeal letter. Clearly articulate the medical necessity of the procedure, treatment, or drug, providing detailed explanations and supporting evidence. Emphasize the potential benefits and outcomes for the patient's health and well-being.
5. Submit the appeal: Follow the payer's specific guidelines for submitting appeals. Ensure that the appeal letter, along with any supporting documentation, is submitted within the designated timeframe. Keep a record of all communication and documentation related to the appeal for future reference.
6. Monitor the progress: Keep track of the appeal's progress by regularly following up with the payer. Maintain open lines of communication and be prepared to provide any additional information or clarification that may be requested during the review process.
7. Consider alternative options: If the appeal is unsuccessful, explore alternative options such as discussing the case with a medical director at the payer's organization or seeking assistance from a healthcare attorney or a specialized RCM consultant who can provide guidance on further steps to take.
Remember, each payer may have specific requirements and processes for addressing code 55. It is essential to familiarize yourself with their guidelines and ensure compliance throughout the entire appeals process.