How To Fix Denial Code 153 | Common Reasons, Next Steps & How To Avoid It

Denial Code 153 means that the payer deems the information submitted does not support this dosage. This denial code indicates that the dosage of a medication or treatment submitted on a claim does not align with the payer’s guidelines or requirements. In this article, we will explore the description of denial code 153, common reasons for its occurrence, next steps to resolve the denial, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 153 is a claim adjustment reason code (CARC) that signifies that the dosage information provided on the claim does not meet the payer’s criteria. This denial indicates that the payer does not consider the dosage submitted as appropriate or supported by the information provided. It suggests that the dosage may be excessive, insufficient, or not in line with the payer’s guidelines for the specific medication or treatment.

2. Common Reasons

The most common reasons for denial code 153 include:

1. Excessive Dosage: The dosage submitted on the claim may exceed the recommended or approved dosage for the specific medication or treatment. Payers have established guidelines and limitations on dosages to ensure patient safety and cost-effectiveness.
2. Insufficient Dosage: Conversely, the dosage provided on the claim may be below the minimum required dosage for the medication or treatment. Payers may deny the claim if they believe the dosage is too low to be effective or meet the patient’s needs.
3. Lack of Supporting Documentation: Payers may require additional documentation or evidence to support the dosage submitted on the claim. If the necessary documentation is missing or incomplete, the claim may be denied under code 153.
4. Non-Compliance with Clinical Guidelines: Payers often have specific clinical guidelines or protocols that outline the appropriate dosages for different medications or treatments. If the submitted dosage does not align with these guidelines, the claim may be denied.
5. Incorrect Coding: Errors in coding, such as selecting the wrong dosage code or using outdated codes, can result in denial code 153. It is crucial to ensure accurate coding to avoid this denial.

3. Next Steps

To resolve denial code 153, follow these next steps:

1. Review the Claim: Carefully review the claim to ensure that the dosage information submitted is accurate and supported by the patient’s medical records and relevant clinical guidelines.
2. Consult Clinical Guidelines: Refer to the payer’s clinical guidelines or protocols to verify the recommended dosages for the specific medication or treatment. Compare the submitted dosage with the guidelines to identify any discrepancies.
3. Provide Additional Documentation: If the denial is due to a lack of supporting documentation, gather the necessary evidence to substantiate the dosage submitted. This may include medical records, physician notes, or any other relevant documentation.
4. Submit an Appeal: If you believe the denial was incorrect or unjustified, submit an appeal to the payer. Include any additional documentation or information that supports the appropriateness of the dosage. Clearly explain why the dosage meets the patient’s needs and complies with the payer’s guidelines.
5. Follow Up with Payer: Maintain open communication with the payer throughout the appeal process. Address any questions or concerns they may have and provide any additional information they request promptly.
6. Consider Alternative Dosages: If the denial is due to an excessive or insufficient dosage, consult with the prescribing physician to determine if an alternative dosage can be used that aligns with the payer’s guidelines.

4. How To Avoid It

To avoid denial code 153 in the future, consider the following steps:

1. Review Payer Guidelines: Familiarize yourself with the payer’s clinical guidelines and protocols regarding dosages for different medications or treatments. Ensure that the dosages submitted on claims adhere to these guidelines.
2. Stay Updated on Coding: Regularly update your knowledge of coding requirements and guidelines. Use the most current and accurate codes when submitting claims to avoid coding errors that may lead to denial code 153.
3. Document Dosage Appropriately: Ensure that the dosage information documented in the patient’s medical records is accurate and aligns with the dosages submitted on claims. Consistency in documentation can help prevent denials.
4. Communicate with Prescribing Physicians: Maintain open communication with prescribing physicians to ensure that the dosages prescribed are appropriate and supported by the patient’s medical condition and clinical guidelines.

5. Example Cases

Here are two examples illustrating denial code 153:

• Example 1: A claim is submitted for a medication with a dosage of 500mg, but the payer’s clinical guidelines state that the maximum recommended dosage is 250mg. The claim is denied under code 153 due to the excessive dosage.
• Example 2: A claim is submitted for a treatment with a dosage of 50 units, but the payer’s guidelines specify that a minimum dosage of 100 units is required for reimbursement. The claim is denied under code 153 due to the insufficient dosage.

Source: Claim Adjustment Reason Codes