Denial code 91 is a dispensing fee adjustment. This means that the claim for reimbursement of a medication's dispensing fee has been adjusted or denied. It could be due to various reasons such as incorrect coding, lack of supporting documentation, or exceeding the allowed quantity or frequency of dispensing.
Common causes of code 91 (Dispensing fee adjustment) are:
1. Incorrect billing: This code may be triggered if the healthcare provider bills for a dispensing fee that is not supported by the documentation or is not in accordance with the payer's guidelines. It could also occur if the provider bills for a dispensing fee that is not eligible for reimbursement under the specific payer's policies.
2. Missing or incomplete documentation: If the necessary documentation to support the dispensing fee is missing or incomplete, it can result in a denial with code 91. This could include missing information such as the date of service, the medication dispensed, or the patient's name.
3. Non-covered medication: Some payers have specific guidelines regarding which medications are covered for dispensing fees. If the medication dispensed is not on the payer's list of covered medications, it can lead to a denial with code 91.
4. Maximum allowable limit exceeded: Payers often have limits on the maximum allowable dispensing fee for certain medications. If the billed dispensing fee exceeds this limit, it can result in a denial with code 91.
5. Incorrect coding: If the healthcare provider uses an incorrect code or modifier when billing for the dispensing fee, it can lead to a denial with code 91. This could include using an outdated or invalid code, or using a code that does not accurately reflect the services provided.
6. Lack of medical necessity: Payers may require documentation of medical necessity for certain medications in order to reimburse for the dispensing fee. If the provider fails to provide sufficient evidence of medical necessity, it can result in a denial with code 91.
7. Contractual agreements: In some cases, the denial with code 91 may be due to contractual agreements between the healthcare provider and the payer. This could include situations where the provider has agreed to accept a lower dispensing fee as part of a negotiated contract.
It is important for healthcare providers to review the specific denial code and associated explanation of benefits (EOB) to determine the exact cause of the denial and take appropriate steps to address and resolve the issue.
Ways to mitigate code 91, which refers to a dispensing fee adjustment, include:
- Accurate documentation: Ensure that all relevant information, such as the patient's medical history, diagnosis, and prescribed medications, is accurately documented. This will help support the necessity of the dispensed medication and minimize the chances of a denial.
- Verify eligibility and coverage: Before dispensing any medication, verify the patient's insurance eligibility and coverage. This will help identify any potential issues or limitations that may lead to a denial. It is important to stay updated on the patient's insurance plan and any changes in coverage.
- Prior authorization: For medications that require prior authorization, make sure to obtain the necessary approval before dispensing. This involves submitting the required documentation and following the specific guidelines set by the insurance company. Failure to obtain prior authorization can result in a denial or adjustment of the dispensing fee.
- Utilize correct coding: Ensure that the correct codes are used when submitting claims for dispensing fees. Familiarize yourself with the specific coding guidelines provided by the insurance company to avoid any coding errors that may lead to a denial.
- Review and appeal denials: In case of a denial or adjustment related to a dispensing fee, thoroughly review the denial reason provided by the insurance company. If you believe the denial is incorrect or unjustified, consider appealing the decision. Provide any additional supporting documentation or information that may help overturn the denial.
- Stay updated on payer policies: Keep yourself informed about the policies and guidelines of different payers. Insurance companies often update their policies, coverage criteria, and reimbursement rates. By staying updated, you can ensure compliance with the payer's requirements and minimize the chances of a denial or adjustment.
- Conduct regular audits: Perform regular internal audits of your billing and coding processes to identify any potential issues or patterns that may lead to denials. This proactive approach will help you address any gaps or errors in your revenue cycle management process and reduce the likelihood of code 91 denials.
Remember, preventing code 91 denials requires attention to detail, accurate documentation, and adherence to payer policies. By implementing these strategies, healthcare providers can minimize the impact of dispensing fee adjustments on their revenue cycle.
The steps to address code 91, the dispensing fee adjustment, are as follows:
- Review the claim: Carefully examine the claim to ensure that all necessary information, such as patient demographics, provider details, and service dates, is accurate and complete. Any missing or incorrect information should be corrected before proceeding.
- Verify coding accuracy: Double-check the coding used for the services provided. Ensure that the correct CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes are used, and that they accurately reflect the services rendered. If any coding errors are identified, make the necessary corrections.
- Check for prior authorization: Determine if the service in question required prior authorization from the insurance payer. If so, confirm that the prior authorization was obtained and submitted along with the claim. If not, initiate the prior authorization process as soon as possible to avoid further denials.
- Review the fee schedule: Consult the fee schedule provided by the insurance payer to verify the approved dispensing fee for the specific service. Ensure that the fee charged aligns with the fee schedule, and make adjustments if necessary.
- Investigate contract agreements: If the provider has a contract agreement with the insurance payer, review the terms and conditions to ensure compliance. Confirm that the dispensing fee adjustment is justified based on the agreed-upon terms, and take appropriate action accordingly.
- Appeal if necessary: If you believe that the dispensing fee adjustment is incorrect or unjustified, consider filing an appeal with the insurance payer. Gather any supporting documentation, such as medical records or additional information, to strengthen your case. Follow the payer's appeal process and submit the appeal within the designated timeframe.
- Monitor trends: Keep track of recurring denials with code 91 to identify any patterns or trends. If multiple claims are being denied for the same reason, investigate the root cause and implement corrective measures to prevent future denials.
Remember, addressing denial code 91 requires a thorough understanding of the specific circumstances surrounding the claim. By following these steps, healthcare providers can effectively address the dispensing fee adjustment and work towards resolving the denial.