Denial code 59 is for claims that were processed based on multiple or concurrent procedure rules. It's important to refer to the 835 Healthcare Policy Identification Segment for more information.
Denial code 59 is used when a claim is processed based on multiple or concurrent procedure rules. This means that the claim includes multiple surgeries or diagnostic imaging procedures that are being performed at the same time or in close proximity. When this denial code is received, it is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) for further information, if it is present.
Common causes of code 59 are:
1. Multiple surgeries: This code may be triggered when multiple surgical procedures are performed on the same patient during the same operative session. Insurance payers may deny payment for certain procedures that are considered bundled or included in the primary procedure.
2. Diagnostic imaging: If multiple diagnostic imaging tests are performed on the same patient during the same visit, code 59 may be used. Insurance payers may deny payment for certain imaging tests that are considered duplicative or unnecessary.
3. Concurrent anesthesia: When multiple anesthesia services are provided concurrently, code 59 may be assigned. Insurance payers may deny payment for additional anesthesia services that are deemed unnecessary or not medically justified.
4. Incorrect coding: Sometimes, code 59 may be assigned due to coding errors or inaccuracies. This could be a result of using the wrong modifier or failing to properly document the need for multiple or concurrent procedures.
5. Lack of documentation: Insufficient documentation to support the medical necessity of multiple or concurrent procedures can lead to the use of code 59. Without proper documentation, insurance payers may deny payment for these services.
It is important for healthcare providers to review their coding practices, ensure accurate documentation, and understand payer policies to minimize denials associated with code 59.
Ways to mitigate code 59 include:
- Ensure accurate documentation: Make sure that all procedures performed are clearly documented in the medical record. This includes documenting the necessity and appropriateness of multiple or concurrent procedures.
- Use modifier codes: Apply the appropriate modifier codes to indicate the specific circumstances that justify the multiple or concurrent procedures. This helps to provide additional information to the payer and can help prevent denials.
- Verify medical necessity: Before performing multiple or concurrent procedures, verify that they are medically necessary. This can be done by reviewing the patient's medical history, consulting with other healthcare professionals, and following evidence-based guidelines.
- Communicate with payers: Establish open lines of communication with payers to understand their specific requirements and policies regarding multiple or concurrent procedures. This can help you align your documentation and coding practices with their expectations.
- Educate staff: Provide ongoing training and education to your staff on proper coding and documentation practices. This will help ensure that everyone involved in the revenue cycle management process understands the importance of accurately capturing and reporting multiple or concurrent procedures.
- Conduct regular audits: Perform regular internal audits to identify any coding or documentation errors related to multiple or concurrent procedures. This proactive approach can help catch and correct issues before they result in denials.
- Stay updated on coding guidelines: Stay informed about any changes or updates to coding guidelines related to multiple or concurrent procedures. This includes staying up to date with the latest versions of coding manuals and attending relevant workshops or webinars.
By implementing these strategies, healthcare providers can reduce the likelihood of denials associated with code 59 and improve their revenue cycle management processes.
The steps to address code 59 are as follows:
- Review the claim details: Carefully examine the claim to ensure that all procedures and services billed are accurate and necessary. Verify if multiple procedures were performed during the same session or if concurrent procedures were conducted.
- Check for documentation: Review the medical records to ensure that there is sufficient documentation supporting the need for multiple or concurrent procedures. Look for evidence of medical necessity and any specific guidelines or requirements outlined by the payer.
- Verify coding accuracy: Double-check the coding for each procedure to ensure that they are correctly assigned. Ensure that the appropriate modifiers are used, if applicable, to indicate the multiple or concurrent nature of the services provided.
- Appeal if necessary: If you believe that the denial is incorrect or unjustified, prepare an appeal. Provide a detailed explanation of why the multiple or concurrent procedures were necessary and supported by medical documentation. Include any relevant guidelines or policies that support your case.
- Communicate with the payer: Reach out to the payer to discuss the denial and seek clarification if needed. Ask for any specific requirements or additional information they may require to reconsider the claim.
- Educate staff and providers: If denials for code 59 are recurring, consider providing education and training to your staff and providers. Ensure they understand the specific guidelines and documentation requirements for billing multiple or concurrent procedures.
- Monitor and track denials: Keep a record of all denials related to code 59. Analyze the patterns and trends to identify any systemic issues that may need to be addressed. Use this information to improve your revenue cycle management processes and prevent future denials.
Remember, addressing denial codes requires attention to detail, accurate documentation, and effective communication with payers. By following these steps, you can increase your chances of successfully resolving denials related to code 59.