How To Fix Denial Code 151 | Common Reasons, Next Steps & How To Avoid It

Denial Code 151 means that the payment for a claim has been adjusted because the payer determines that the information submitted does not support the number or frequency of services billed. In this article, we will provide a description of denial code 151, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code 151 cases.

2. Description

Denial Code 151 is a claim adjustment reason code (CARC) that indicates the payment for a claim has been adjusted due to insufficient supporting information for the number or frequency of services billed. This means that the payer has determined that the documentation or evidence provided does not justify the quantity or frequency of the services claimed. As a result, the payment for the claim is adjusted accordingly.

2. Common Reasons

The most common reasons for denial code 151 include:

1. Lack of Medical Necessity Documentation: One of the main reasons for denial code 151 is the absence or inadequacy of medical necessity documentation. Payers require sufficient evidence to support the need for the number or frequency of services billed. Without proper documentation, the payer may deem the services as unnecessary or excessive, leading to a denial.
2. Incomplete or Inaccurate Billing Information: Denial code 151 can also occur if the billing information submitted is incomplete or inaccurate. This can include missing or incorrect codes, dates, or other relevant details. In such cases, the payer may not have enough information to assess the appropriateness of the billed services, resulting in a denial.
3. Contradictory or Inconsistent Documentation: If the documentation submitted contradicts or is inconsistent with the billed services, denial code 151 may be applied. This can happen when the documentation does not align with the reported number or frequency of services, raising doubts about the accuracy or validity of the claim.
4. Insufficient Supporting Documentation: In some instances, the documentation provided may not sufficiently support the number or frequency of services billed. This can occur when the documentation lacks details, fails to provide a clear rationale for the services, or does not adequately demonstrate the medical necessity for the reported quantity or frequency.
5. Non-Compliance with Payer Policies: Denial code 151 can also be triggered if the billed services do not comply with the specific policies or guidelines set by the payer. This can include limitations on the number or frequency of certain services or procedures. If the billed services exceed the allowed limits, the claim may be denied.

3. Next Steps

If you receive denial code 151, here are the next steps to resolve the denial:

1. Review the Denial Explanation: Carefully review the explanation provided with the denial code to understand the specific reason for the denial. This will help you identify the areas that need to be addressed.
2. Assess the Supporting Documentation: Evaluate the supporting documentation submitted with the claim. Determine if it adequately justifies the number or frequency of services billed. If there are any gaps or deficiencies, gather additional documentation to strengthen your case.
3. Address Documentation Issues: If the denial is due to insufficient or inconsistent documentation, take steps to rectify the issue. Ensure that all necessary information is included, and that the documentation aligns with the billed services. If needed, consult with the healthcare provider to obtain any missing or clarifying documentation.
4. Submit an Appeal: If you believe that the denial was unjustified and have gathered the necessary supporting documentation, submit an appeal to the payer. Clearly explain why the number or frequency of services billed is appropriate and provide the additional documentation to support your claim.
5. Follow Up with the Payer: Stay in communication with the payer throughout the appeal process. Follow up on the status of your appeal and provide any additional information or clarification requested by the payer.
6. Seek Expert Assistance: If you encounter challenges in resolving the denial, consider seeking assistance from a healthcare billing expert or consultant. They can provide guidance on navigating the appeals process and help strengthen your case.

4. How To Avoid It

To avoid denial code 151 in the future, consider the following tips:

1. Ensure Comprehensive Documentation: Document all relevant information, including the medical necessity, in the patient’s records. Provide clear and detailed explanations for the number or frequency of services rendered.
2. Follow Payer Guidelines: Familiarize yourself with the specific policies and guidelines of each payer. Adhere to their requirements regarding the number or frequency of services allowed.
3. Double-Check Billing Information: Verify that all billing information, including codes, dates, and quantities, is accurate and complete before submitting the claim. This will help prevent denials due to incomplete or incorrect information.
4. Regularly Educate Staff: Keep your billing and administrative staff updated on the latest payer policies and guidelines. Provide training on proper documentation practices and emphasize the importance of accurate and comprehensive records.

5. Example Cases

Here are two examples of denial code 151:

• Example 1: A healthcare provider submits a claim for 10 physical therapy sessions for a patient. However, the documentation provided does not clearly demonstrate the medical necessity for such a high frequency of sessions. As a result, the claim is denied under code 151.
• Example 2: A dentist bills for 5 dental cleanings for a patient within a short period of time. The payer’s policy states that only 2 cleanings are covered per year. Since the billed services exceed the allowed frequency, the claim is denied under code 151.

Source: Claim Adjustment Reason Codes