Denial Code 223 means that a claim has been denied due to a mandated federal, state, or local law/regulation that is not covered by any other code. In this article, we will provide a description of denial code 223, 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 223 cases.
2. Description
Denial Code 223 is an adjustment code that indicates a claim has been denied because it does not comply with a mandated federal, state, or local law/regulation. This denial code is used when there is no existing code that specifically addresses the violation, and a new code has not yet been created. It serves as a general catch-all code for denials related to regulatory non-compliance.
2. Common Reasons
The most common reasons for denial code 223 are:
- Lack of Compliance with New Regulations: Denial code 223 may be triggered when a claim does not meet the requirements of a recently implemented federal, state, or local law/regulation. This could include documentation, coding, or billing practices that are not in line with the new regulations.
- Incomplete or Inaccurate Information: Claims that lack necessary information or contain inaccuracies may result in denial code 223. This could include missing documentation, incomplete patient information, or errors in coding or billing.
- Failure to Obtain Prior Authorization: Some procedures or services may require prior authorization from the insurance company. If the provider fails to obtain the necessary authorization before performing the service, the claim may be denied under code 223.
- Non-Compliance with Documentation Requirements: Certain regulations may require specific documentation to support the medical necessity of a procedure or service. If the provider fails to provide the required documentation, the claim may be denied under code 223.
3. Next Steps
To resolve denial code 223, follow these next steps:
- Review the Denial Explanation: Carefully read the denial explanation provided by the insurance company. Understand the specific regulation or requirement that the claim did not comply with.
- Identify the Non-Compliance Issue: Determine the exact reason for the non-compliance. This could involve reviewing the claim, documentation, coding, or billing practices to identify any errors or omissions.
- Address the Non-Compliance Issue: Take the necessary steps to rectify the non-compliance issue. This may involve updating documentation, correcting coding or billing errors, or obtaining the required prior authorization.
- Resubmit the Claim: Once the non-compliance issue has been addressed, resubmit the claim to the insurance company. Ensure that all necessary documentation and information are included to support the claim.
- Follow Up with the Insurance Company: Monitor the status of the resubmitted claim and follow up with the insurance company if necessary. Communicate any additional information or documentation that may be requested.
4. How To Avoid It
To avoid denial code 223 in the future, consider the following tips:
- Stay Updated on Regulations: Stay informed about any new or updated federal, state, or local regulations that may impact your billing and coding practices. Regularly review industry updates and communicate with relevant regulatory bodies.
- Ensure Compliance with Documentation Requirements: Familiarize yourself with the specific documentation requirements for different procedures and services. Make sure your documentation accurately reflects the medical necessity and meets the regulatory standards.
- Obtain Prior Authorization: Understand the procedures or services that require prior authorization from the insurance company. Establish a process to ensure that all necessary authorizations are obtained before providing the service.
- Double-Check Coding and Billing: Implement a system of checks and balances to ensure accurate coding and billing practices. Regularly audit claims to identify any errors or discrepancies that could lead to non-compliance.
5. Example Cases
Here are two examples of denial code 223:
- Example 1: A healthcare provider submits a claim for a procedure that requires prior authorization. However, the provider failed to obtain the necessary authorization before performing the procedure. As a result, the claim is denied under code 223.
- Example 2: A provider submits a claim for a service that does not meet the documentation requirements set forth by a new regulation. The claim is denied under code 223 due to non-compliance with the documentation requirements.
