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What is Denial Code 173

Denial code 173 signifies that a service or equipment was not ordered by a physician. This indicates that the healthcare provider submitted a claim for services or equipment that were not requested or approved by a doctor, leading the insurance company to deny the claim.

Common Causes of CARC 173 (denial code 173)
The typical reasons for code 173 are:

1. Inadequate documentation: The service or equipment may be unprescribed by a physician due to insufficient records. This could involve missing or partial medical documents, unclear handwriting, or failure to present essential details like diagnosis codes or medical necessity.

2. Non-adherence to medical guidelines: The service or equipment may not conform to the standards or criteria established by insurance payers or regulatory organizations. This could stem from the service or equipment being viewed as experimental or investigational, failing to meet the required criteria for coverage, or not being classified as medically essential for the patient’s condition.

3. Absence of prior authorization: Certain insurance plans mandate prior approval for specific services or equipment. If the provider neglected to secure the necessary authorization before delivering the service or equipment, it may result in a denial coded as 173.

4. Mistakes in coding or billing: Errors in coding or billing can also result in denials linked to code 173. This might encompass the use of incorrect procedure or diagnosis codes, billing for services or equipment that were never provided, or filing claims with incorrect or incomplete data.

5. Inadequate medical necessity documentation: Insurance companies often require comprehensive documentation to validate the medical necessity of a service or equipment. If the provider fails to furnish robust documentation to support the need for the service or equipment, it may result in a code 173 denial.

6. Lack of coverage: In certain instances, the service or equipment may simply not be included in the patient’s insurance plan. This might arise from exclusions or limitations outlined in the policy, or the service or equipment may not be viewed as medically necessary for the patient’s condition.

Providers in the healthcare field must address these common causes of code 173 to reduce denials and guarantee appropriate reimbursement for provided services and equipment. Achieving this requires comprehensive documentation, compliance with medical standards, obtaining necessary prior approvals, accurate coding and billing practices, and ensuring the medical necessity of the service or equipment is thoroughly documented.

Ways to Diminish Denial Code 173
Approaches to alleviate code 173 include:

Ensure proper documentation: To avert this denial code, it is paramount to possess precise and detailed documentation that explicitly demonstrates the medical necessity for the service or equipment. This encompasses recording the physician’s order or prescription for the specific service or equipment.

Enhance communication with physicians: Foster solid communication with physicians to ensure they understand the requisite documentation standards. Regularly educate and remind them of the importance of prescribing services and equipment per the payer’s guidelines.

Execute pre-authorization processes: Prior to delivering any services or equipment, establish a pre-authorization process to confirm that the service or equipment is medically needed and ordered by a physician. This will assist in identifying any potential issues before submitting the claim, consequently decreasing the likelihood of a denial.

Train staff on coding guidelines: Provide extensive training to coding and billing staff to ensure they are familiar with the payer’s coding regulations. This will aid them in accurately assigning the corresponding codes and guaranteeing that services and equipment are properly documented and prescribed.

Conduct regular audits: Implement routine internal audits to pinpoint potential issues or lapses in documentation. This will help highlight areas needing improvement and facilitate proactive corrective actions.

Stay up to date with payer policies: Remain informed about the most recent policies and guidelines from payers concerning service and equipment prescriptions. Regularly review and refresh internal processes to align with these policies, hence reducing the risk of denials associated with code 173.

Utilize technology solutions: Adopt technology solutions such as electronic health record (EHR) systems or revenue cycle management (RCM) software that can aid in streamlining documentation processes and ensuring that all requisite information is accurately captured.
By applying these strategies, healthcare providers can alleviate denial code 173 and enhance their revenue cycle management practices.

How to Address Denial Code 173

To respond to code 173 (Service/equipment was not prescribed by a physician), follow these steps:

1. Review the claim documentation: Thoroughly inspect the claim documentation to verify that all needed information is included. Confirm whether the service or equipment in question was indeed not prescribed by a physician.

2. Authenticate the referring provider: Verify the identity and qualifications of the referring provider. Ensure they are a licensed medical professional or other competent healthcare individual permitted to prescribe the particular service or equipment.

3. Engage with the referring provider: Contact the referring provider to discuss the denial code and to collect further details. Seek clarification on whether the service or equipment was officially prescribed and if there was any mistake or oversight in the documentation.

4. Acquire corroborative documentation: If the service or equipment was indeed ordered by a physician, gather all pertinent supporting documentation. This may include the initial prescription, medical records, progress reports, or any other proof that affirms the medical necessity of the service or equipment.

5. File an appeal or revised claim: Based on the information collected, submit an appeal or revised claim to the insurer. Include all required documentation and a clear rationale as to why the denial code is erroneous or warrants reconsideration.

6. Follow up with the insurer: Monitor the appeal or revised claim and follow up with the insurer to confirm it is being processed. Maintain communication with the insurer’s representative to address any inquiries or concerns they may possess.

7. Observe and track denials: Consistently observe and track denial patterns, including code 173, to uncover any trends or recurring challenges. This will assist in implementing proactive strategies to avert similar denials in the future.

Keep in mind, understanding the specific denial code and its implications is vital for effectively managing it. By following these steps, healthcare providers can enhance their chances of successfully addressing denial code 173 and securing appropriate compensation for the services and equipment rendered.