Denial code 90 is used for ingredient cost adjustment specifically related to pharmaceuticals. This code indicates that the claim has been denied due to an adjustment in the cost of the ingredients used in the pharmaceutical product.
Common causes of code 90 are:
1. Incorrect coding: One of the common causes of code 90 is when the pharmaceuticals are not coded correctly. This can happen if the wrong code is used or if there is a mistake in the coding process.
2. Lack of documentation: Another cause of code 90 is when there is a lack of proper documentation to support the pharmaceutical usage. This can include missing or incomplete documentation of the medication prescribed, dosage, frequency, or duration.
3. Non-covered medications: Code 90 may also be triggered when the pharmaceuticals used are not covered by the patient's insurance plan. This can occur if the medication is considered experimental, investigational, or not included in the formulary of the insurance provider.
4. Prior authorization requirements: Some insurance plans require prior authorization for certain medications. If the healthcare provider fails to obtain the necessary authorization before prescribing the pharmaceutical, it can result in code 90.
5. Maximum allowable quantity exceeded: Code 90 can be caused when the quantity of pharmaceuticals prescribed exceeds the maximum allowable limit set by the insurance provider. This can happen if the healthcare provider does not adhere to the quantity restrictions specified by the insurance plan.
6. Inadequate medical necessity documentation: Insufficient documentation of medical necessity can lead to code 90. If the healthcare provider fails to provide adequate justification for the pharmaceutical usage based on the patient's medical condition, the claim may be denied with this code.
7. Billing errors: Billing errors, such as incorrect patient information, incorrect dates of service, or incorrect billing codes, can also result in code 90. These errors can occur during the claim submission process and may lead to claim denials.
It is important for healthcare providers to address these common causes of code 90 to minimize claim denials and ensure proper reimbursement for pharmaceutical usage.
Ways to mitigate code 90 include:
- Ensure accurate documentation: To prevent this code, it is crucial to have accurate and detailed documentation of all pharmaceuticals used. This includes recording the name, dosage, quantity, and any other relevant information. Accurate documentation helps in justifying the ingredient cost and reduces the chances of denials.
- Verify medical necessity: Before prescribing or administering any pharmaceutical, it is important to verify the medical necessity of the drug. This involves ensuring that the medication is appropriate for the patient's condition and aligns with the established treatment guidelines. By doing so, healthcare providers can minimize the risk of denials related to code 90.
- Conduct regular audits: Regularly auditing the pharmaceutical usage and associated documentation can help identify any discrepancies or errors that may lead to code 90 denials. By conducting internal audits, healthcare providers can proactively address any issues and make necessary improvements to their processes.
- Stay updated with coding guidelines: It is essential to stay updated with the latest coding guidelines and requirements related to pharmaceuticals. This includes being aware of any changes in coding rules, documentation requirements, or specific instructions for using code 90. By staying informed, healthcare providers can ensure compliance and reduce the likelihood of denials.
- Implement effective communication: Effective communication between healthcare providers, pharmacists, and billing staff is crucial to prevent code 90 denials. Clear and concise communication ensures that everyone involved understands the specific requirements and guidelines related to pharmaceutical usage. This helps in avoiding any misunderstandings or errors that may result in denials.
- Provide staff training: Proper training of staff members involved in the revenue cycle management process is essential to prevent code 90 denials. This includes educating them about the specific requirements for pharmaceutical documentation, coding guidelines, and any other relevant information. Well-trained staff members are more likely to accurately document and code pharmaceuticals, reducing the risk of denials.
By implementing these strategies, healthcare providers can mitigate code 90 denials and improve their revenue cycle management processes.
The steps to address code 90, Ingredient cost adjustment, are as follows:
- Review the claim: Carefully examine the claim to ensure that the pharmaceutical item in question is indeed eligible for reimbursement under the specific healthcare policy.
- Verify documentation: Check if the necessary documentation, such as the prescription, medication administration record, and any other supporting documents, are complete and accurate. Ensure that the pharmaceutical item is medically necessary and appropriately prescribed.
- Evaluate coding accuracy: Double-check the coding used for the pharmaceutical item. Ensure that the correct Healthcare Common Procedure Coding System (HCPCS) or National Drug Code (NDC) is assigned to the medication. Any discrepancies or errors in coding should be corrected.
- Confirm pricing: Validate the pricing of the pharmaceutical item. Compare the billed amount with the contracted rate or the fee schedule. If there are any discrepancies, investigate and rectify them accordingly.
- Provide additional information if required: In some cases, additional information may be necessary to support the reimbursement of the pharmaceutical item. This could include documentation of prior authorization, medical necessity, or any other relevant details. If required, gather and submit this information promptly.
- Appeal if necessary: If the denial persists despite following the above steps, consider filing an appeal. Prepare a strong case by providing all relevant documentation and supporting evidence to demonstrate the medical necessity and appropriateness of the pharmaceutical item.
- Monitor trends: Keep track of recurring denials with code 90. If there is a pattern of denials for the same reason, investigate the root cause and implement corrective measures to prevent future denials.
Remember, addressing denial code 90 requires a thorough understanding of the specific healthcare policy, accurate coding, and proper documentation. By following these steps, healthcare providers can effectively address code 90 and ensure appropriate reimbursement for pharmaceutical items.