Denial Code 213 means that a claim has been denied due to non-compliance with the physician self-referral prohibition legislation or payer policy. Below you can find the description, common reasons for denial code 213, next steps, how to avoid it, and examples.
2. Description
Denial Code 213 is a Claim Adjustment Reason Code (CARC) that indicates a claim has been denied because it does not comply with the physician self-referral prohibition legislation or payer policy. This means that the services billed are in violation of regulations or policies that restrict referrals to certain providers or entities. The denial is a result of the claim not meeting the requirements set forth by the legislation or payer policy.
2. Common Reasons
The most common reasons for denial code 213 are:
- Referral to Prohibited Providers: Denial code 213 may occur when a claim involves a referral to a provider or entity that is prohibited under the physician self-referral prohibition legislation or payer policy. This could include referrals to entities in which the referring physician has a financial interest or referrals that do not meet the requirements for exceptions or safe harbors.
- Failure to Meet Documentation Requirements: Claims may be denied under code 213 if the necessary documentation to support the referral or service is not provided. This could include missing or incomplete documentation that demonstrates compliance with the legislation or payer policy.
- Incorrect Coding or Billing: Inaccurate coding or billing practices can also lead to denial code 213. If the services billed do not align with the requirements of the legislation or payer policy, the claim may be denied.
- Lack of Awareness or Understanding: Providers may be unaware of the specific requirements of the physician self-referral prohibition legislation or payer policy, leading to unintentional violations and subsequent denials.
3. Next Steps
You can address denial code 213 by taking the following steps:
- Review Legislation or Payer Policy: Familiarize yourself with the specific requirements outlined in the physician self-referral prohibition legislation or payer policy. Understand the restrictions and exceptions that apply to referrals and services.
- Assess Compliance: Evaluate your current practices to ensure compliance with the legislation or payer policy. Review referral patterns, documentation processes, and coding practices to identify any potential areas of non-compliance.
- Education and Training: Provide education and training to your staff to ensure they understand the requirements of the legislation or payer policy. This can help prevent unintentional violations and denials.
- Documentation Improvement: Enhance your documentation processes to ensure all necessary information is captured and included in the claim. This includes documenting the medical necessity of the referral or service and any exceptions or safe harbors that apply.
- Appeal or Correct Denials: If a claim is denied under code 213 and you believe it was in error, follow the appropriate appeals process to challenge the denial. Provide any additional documentation or information that supports compliance with the legislation or payer policy.
4. How To Avoid It
To avoid denial code 213 in the future, consider the following strategies:
- Stay Informed: Stay up to date with any changes or updates to the physician self-referral prohibition legislation or payer policy. Regularly review guidelines and communicate any updates to your staff.
- Implement Compliance Measures: Establish internal processes and controls to ensure compliance with the legislation or payer policy. This may include regular audits, staff training, and documentation reviews.
- Utilize Compliance Resources: Seek guidance from industry resources, such as professional associations or legal counsel, to ensure your practices align with the requirements of the legislation or payer policy.
- Monitor Referral Patterns: Regularly monitor referral patterns to identify any potential deviations or patterns that may indicate non-compliance. Address any concerns promptly to prevent denials.
5. Example Cases
Below are two examples of denial code 213:
- Example 1: A provider refers a patient to a diagnostic imaging center in which they have a financial interest, in violation of the physician self-referral prohibition legislation. The claim is denied under code 213.
- Example 2: A provider bills for a service that requires a referral from a primary care physician, but no referral documentation is included with the claim. The claim is denied under code 213 due to failure to meet documentation requirements.
