How To Fix Denial Code 194 | Common Reasons, Next Steps & How To Avoid It

Denial Code 194 means that the anesthesia performed during a procedure was done by the operating physician, the assistant surgeon, or the attending physician. In this article, we will provide a detailed description of denial code 194, 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 194 cases.

2. Description

Denial Code 194 is a specific Claim Adjustment Reason Code (CARC) that indicates that the anesthesia performed during a procedure was carried out by the operating physician, the assistant surgeon, or the attending physician. This code is used by insurance companies to deny payment for anesthesia services when they are provided by these specific individuals. It is important to note that denial code 194 is applicable only in cases where the insurance policy explicitly states that anesthesia services must be performed by an anesthesiologist or a certified nurse anesthetist.

2. Common Reasons

The most common reasons for denial code 194 are:

1. Non-compliance with Insurance Policy: Denial code 194 occurs when the anesthesia services are provided by the operating physician, the assistant surgeon, or the attending physician, instead of an anesthesiologist or a certified nurse anesthetist, as required by the insurance policy. This can happen due to a lack of awareness or understanding of the policy requirements.
2. Lack of Documentation: Insurance companies may deny claims under denial code 194 if there is insufficient documentation to prove that the anesthesia services were performed by an anesthesiologist or a certified nurse anesthetist. Incomplete or inaccurate documentation can lead to claim denials.
3. Incorrect Billing: In some cases, denial code 194 may be triggered due to billing errors. This can include incorrect coding or incorrect identification of the provider who performed the anesthesia services. Such errors can result in the claim being denied under denial code 194.

3. Next Steps

If you receive a denial under code 194, here are the next steps to resolve the issue:

1. Review the Insurance Policy: Carefully review the insurance policy to determine the specific requirements for anesthesia services. Ensure that the services were provided by an anesthesiologist or a certified nurse anesthetist, as stated in the policy.
2. Check Documentation: Verify that the documentation supporting the claim clearly indicates that the anesthesia services were performed by an anesthesiologist or a certified nurse anesthetist. If there are any gaps or inaccuracies in the documentation, work with the provider to obtain the necessary documentation.
3. Appeal the Denial: If you believe that the denial was made in error or that the anesthesia services were indeed performed by an anesthesiologist or a certified nurse anesthetist, file an appeal with the insurance company. Include all relevant documentation and provide a detailed explanation of why the denial should be overturned.
4. Seek Provider Support: Engage with the provider who performed the anesthesia services and seek their assistance in resolving the denial. They may be able to provide additional documentation or clarification to support the claim.
5. Follow Up: Stay in communication with the insurance company throughout the appeals process. Keep track of all correspondence and ensure that any requested information or documentation is promptly provided.

4. How To Avoid It

To avoid denial code 194 in the future, consider the following tips:

1. Review Insurance Policies: Familiarize yourself with the specific requirements of each insurance policy regarding anesthesia services. Ensure that the services are performed by an anesthesiologist or a certified nurse anesthetist, as stated in the policy.
2. Ensure Accurate Documentation: Maintain accurate and complete documentation of all anesthesia services. Clearly indicate the provider who performed the services and include any necessary supporting documentation, such as the provider’s credentials.
3. Train Staff: Educate your staff on the requirements of insurance policies regarding anesthesia services. Ensure that they are aware of the need to accurately document and code the services and to verify that the services are performed by the appropriate provider.
4. Regularly Review Billing Practices: Conduct regular audits of your billing practices to identify any potential errors or discrepancies. This can help catch and correct any issues before claims are submitted.

5. Example Cases

Here are two examples of denial code 194:

• Example 1: A patient undergoes a surgical procedure, and the attending physician performs the anesthesia services. However, the insurance policy explicitly states that anesthesia services must be provided by an anesthesiologist. As a result, the claim is denied under denial code 194.
• Example 2: An assistant surgeon performs the anesthesia services during a procedure, but the insurance policy requires that anesthesia services be provided by a certified nurse anesthetist. The claim is denied under denial code 194 due to non-compliance with the policy requirements.

Source: Claim Adjustment Reason Codes