Denial Code 155 means that a claim has been denied because the patient refused the service or procedure. Below you can find the description, common reasons for denial code 155, next steps, how to avoid it, and examples.
2. Description
Denial Code 155 is a Claim Adjustment Reason Code (CARC) and is described as ‘Patient Refused Service/Procedure’. This code indicates that the claim has been denied because the patient declined to receive the service or procedure that was billed. It is important to note that this denial code does not imply any fault on the part of the healthcare provider or the insurance company, but rather reflects the patient’s decision to refuse the recommended treatment.
2. Common Reasons
The most common reasons for denial code 155 are:
- Patient Choice: The primary reason for denial code 155 is that the patient has made a conscious decision to refuse the recommended service or procedure. This could be due to personal beliefs, concerns about the risks or side effects, financial constraints, or a preference for alternative treatment options.
- Lack of Informed Consent: In some cases, the patient may refuse the service or procedure because they feel that they were not adequately informed about the risks, benefits, or alternatives. This could be a result of poor communication between the healthcare provider and the patient, leading to a lack of understanding or trust.
- Insurance Coverage Limitations: Denial code 155 may also occur if the patient’s insurance policy does not cover the specific service or procedure that was recommended. In such cases, the patient may choose to refuse the treatment due to concerns about out-of-pocket expenses.
- Second Opinion: Patients may refuse a service or procedure if they seek a second opinion and receive conflicting recommendations. In such situations, the patient may choose to follow the advice of the healthcare provider who provided the second opinion.
- Personal Circumstances: Patients may refuse a service or procedure due to personal circumstances, such as pregnancy, existing medical conditions, or other factors that make the recommended treatment unsuitable or risky for them.
3. Next Steps
When faced with denial code 155, the following steps can be taken:
- Document Patient Refusal: It is important to document the patient’s refusal in the medical records. This should include the reasons provided by the patient for refusing the service or procedure, as well as any discussions or attempts to address their concerns.
- Review Informed Consent Process: Evaluate the informed consent process to ensure that patients are adequately informed about the risks, benefits, and alternatives of the recommended treatment. This may involve improving communication, providing written materials, or offering additional opportunities for discussion.
- Explore Alternative Options: If the patient refuses a specific service or procedure, healthcare providers should explore alternative treatment options that may be more acceptable to the patient. This could involve considering different approaches, medications, or therapies that align with the patient’s preferences and concerns.
- Engage in Shared Decision-Making: Collaborate with the patient to make informed decisions about their healthcare. This involves discussing the risks, benefits, and alternatives of different treatment options, taking into account the patient’s values, preferences, and circumstances.
- Provide Education and Support: Offer educational resources and support to help patients make informed decisions. This may include providing information about the recommended treatment, addressing misconceptions or fears, and connecting patients with support groups or counseling services.
- Respect Patient Autonomy: Ultimately, it is important to respect the patient’s autonomy and their right to make decisions about their own healthcare. While healthcare providers can provide guidance and recommendations, the final decision rests with the patient.
4. How To Avoid It
To avoid denial code 155 in the future, healthcare providers can take the following steps:
- Enhance Communication: Improve communication with patients to ensure that they fully understand the recommended treatment options, including the risks, benefits, and alternatives. This may involve using plain language, visual aids, or involving interpreters if necessary.
- Provide Informed Consent: Ensure that patients receive appropriate informed consent for all recommended services or procedures. This includes providing written materials, explaining the treatment in detail, and addressing any questions or concerns the patient may have.
- Verify Insurance Coverage: Before recommending a specific service or procedure, verify the patient’s insurance coverage to ensure that it will be covered. If there are any limitations or exclusions, discuss them with the patient and explore alternative options if necessary.
- Encourage Second Opinions: Encourage patients to seek second opinions if they have concerns or doubts about the recommended treatment. This can help ensure that patients are fully informed and comfortable with their healthcare decisions.
- Offer Supportive Care: Provide comprehensive care that addresses the patient’s physical, emotional, and psychosocial needs. This can help build trust and rapport, making patients more likely to follow through with recommended treatments.
5. Example Cases
Below are two examples of denial code 155:
- Example 1: A patient is recommended to undergo a surgical procedure, but they refuse due to concerns about potential complications and the recovery process. The claim is denied under denial code 155, as the patient made an informed decision to decline the procedure.
- Example 2: A patient is advised to undergo a series of chemotherapy treatments, but they refuse due to personal beliefs and a preference for alternative therapies. The claim is denied under denial code 155, as the patient chose not to proceed with the recommended treatment.
