Denial code 78 is used to indicate that the insurance company has determined that the number of days or the room charge for a particular service is not covered under the patient's insurance plan. This means that the insurance company will not reimburse the healthcare provider for those specific days or the associated room charge.
Common causes of code 78 are:
1. Lack of prior authorization: Insurance companies often require prior authorization for certain services or procedures. If the healthcare provider fails to obtain the necessary authorization, the insurance company may deny coverage for the non-covered days or room charges.
2. Exceeding the maximum allowed days: Insurance plans typically have a maximum number of days they will cover for a particular service or procedure. If the patient stays in the hospital or receives services beyond the allowed limit, the insurance company may deny coverage for the additional days, resulting in code 78.
3. Inappropriate level of care: Insurance companies have specific criteria for determining the appropriate level of care for a patient. If the healthcare provider places the patient in a higher level of care than deemed necessary by the insurance company, they may deny coverage for the non-covered days or room charges.
4. Lack of medical necessity: Insurance companies require services or procedures to be medically necessary for coverage. If the insurance company determines that the non-covered days or room charges were not medically necessary, they may deny coverage and assign code 78.
5. Documentation errors: Inaccurate or incomplete documentation can lead to denials. If the healthcare provider fails to document the medical necessity or fails to provide sufficient supporting documentation, the insurance company may deny coverage for the non-covered days or room charges.
6. Billing errors: Mistakes in the billing process, such as incorrect coding or incorrect submission of claims, can result in denials. If the healthcare provider submits a claim with errors related to the non-covered days or room charges, the insurance company may assign code 78.
7. Policy exclusions: Insurance plans often have specific exclusions for certain services or procedures. If the non-covered days or room charges fall under these exclusions, the insurance company may deny coverage and assign code 78.
8. Retroactive denial: Sometimes, insurance companies may retroactively deny coverage for non-covered days or room charges after initially approving them. This can occur if the insurance company identifies an error or discrepancy during their review process.
It is important for healthcare providers to address these common causes to minimize denials and ensure proper reimbursement for their services.
Ways to mitigate code 78 (Non-Covered days/Room charge adjustment) include:
1. Verify insurance coverage: Before admitting a patient, it is crucial to verify their insurance coverage and ensure that the services provided are covered under their plan. This can help prevent denials related to non-covered days or room charges.
2. Obtain pre-authorization: For certain procedures or services, obtaining pre-authorization from the insurance company is necessary. By proactively seeking pre-authorization, you can ensure that the services provided will be covered, reducing the likelihood of denials related to non-covered days or room charges.
3. Accurate documentation: Ensure that all medical records and documentation accurately reflect the services provided and the medical necessity for those services. Clear and detailed documentation can help support the claim and minimize the chances of denials related to non-covered days or room charges.
4. Stay updated with payer policies: Keep track of any changes in payer policies regarding coverage for specific services or procedures. Regularly review and update your knowledge of these policies to ensure that the services provided align with the payer's guidelines, reducing the risk of denials related to non-covered days or room charges.
5. Communicate with payers: Establish open lines of communication with payers to clarify any uncertainties regarding coverage or billing requirements. By proactively engaging with payers, you can address any potential issues or discrepancies before submitting the claim, minimizing the chances of denials related to non-covered days or room charges.
6. Conduct regular internal audits: Implement a system of regular internal audits to identify any potential coding or billing errors. By proactively identifying and rectifying any issues, you can reduce the likelihood of denials related to non-covered days or room charges.
7. Educate staff: Provide comprehensive training to your staff on coding and billing practices, payer policies, and documentation requirements. Well-informed and knowledgeable staff can help ensure accurate claim submission, reducing the risk of denials related to non-covered days or room charges.
By implementing these strategies, healthcare providers can mitigate code 78 denials and improve their revenue cycle management.
The steps to address code 78, Non-Covered days/Room charge adjustment, are as follows:
- Review the patient's insurance coverage: Verify the patient's insurance policy to determine if the non-covered days or room charges are indeed not covered under their plan. This can be done by checking the insurance company's website or contacting their customer service.
- Check for coding errors: Review the medical records and billing documentation to ensure that the services provided were accurately coded and billed. Look for any potential errors or discrepancies that may have led to the non-covered days or room charge adjustment.
- Appeal the denial: If you believe that the non-covered days or room charge adjustment was made in error, prepare a strong and well-documented appeal. Include supporting documentation such as medical records, physician notes, and any other relevant information that can help justify the services provided.
- Communicate with the insurance company: Reach out to the insurance company's provider relations or claims department to discuss the denial and seek clarification. Ask for specific reasons for the denial and any additional information or documentation they may require to reconsider the claim.
- Follow up regularly: Keep track of the appeal process and follow up with the insurance company regularly to ensure that your appeal is being reviewed and processed. Document all communication and maintain a record of the dates, names, and details of each interaction.
- Consider a payment plan: If the denial is upheld and the patient is responsible for the non-covered days or room charge adjustment, work with the patient to establish a feasible payment plan. This can help alleviate any financial burden on the patient and ensure that the healthcare provider receives some reimbursement for the services provided.
Remember, each denial code may require a unique approach, so it's essential to thoroughly understand the specific circumstances surrounding the denial and tailor your response accordingly.