How To Fix Denial Code 231 | Common Reasons, Next Steps & How To Avoid It

Denial Code 231 means that mutually exclusive procedures cannot be done in the same day/setting. This denial code indicates that the insurance company will not make payment for procedures that are considered mutually exclusive and should not be performed together. In this article, we will explore the common reasons for denial code 231, the next steps to take when faced with this denial, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 231 is a claim adjustment reason code (CARC) that signifies that mutually exclusive procedures were performed in the same day/setting. This means that the insurance company will not reimburse for these procedures as they are considered incompatible or redundant when performed together. The 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) can provide further details on the specific policy that led to the denial.

2. Common Reasons

The most common reasons for denial code 231 are:

1. Procedure Incompatibility: Denial code 231 often occurs when the performed procedures are considered mutually exclusive. This means that the insurance company has determined that the procedures should not be performed together due to their nature or the potential for duplication of services.
2. Lack of Medical Necessity: Another common reason for denial code 231 is the lack of medical necessity for performing both procedures in the same day/setting. Insurance companies may require that procedures be spaced out to ensure that they are medically necessary and not excessive or redundant.
3. Incorrect Coding: Denial code 231 can also result from coding errors. If the procedures were coded incorrectly, it may appear that they are mutually exclusive when, in fact, they are not. It is essential to ensure accurate coding to avoid this type of denial.
4. Insufficient Documentation: In some cases, denial code 231 may be issued due to insufficient documentation. If the medical records do not clearly justify the need for performing both procedures together, the insurance company may deny the claim based on lack of supporting evidence.

3. Next Steps

If you receive denial code 231, here are the next steps to take:

1. Review the Explanation of Benefits (EOB): Carefully review the EOB provided by the insurance company to understand the specific reasons for the denial. Look for any additional information or documentation required to support the claim.
2. Consult with the Healthcare Provider: Reach out to the healthcare provider who performed the procedures to discuss the denial and gather any necessary documentation or clarification. They may be able to provide additional information to support the claim and address any coding or medical necessity concerns.
3. Submit an Appeal: If you believe that the denial was incorrect or unjustified, submit an appeal to the insurance company. Include any relevant documentation, such as medical records or expert opinions, to support your case. Follow the insurance company’s appeal process and provide all requested information within the specified timeframe.
4. Seek Coding Expertise: If the denial was due to coding errors, consult with a coding expert to ensure accurate coding in future claims. They can help identify any discrepancies or potential conflicts between procedures to avoid future denials under code 231.

4. How To Avoid It

To prevent denial code 231 in the future, consider the following steps:

1. Review Insurance Policies: Familiarize yourself with the insurance policies and guidelines regarding mutually exclusive procedures. Understand which procedures are considered incompatible and should not be performed together.
2. Perform Procedures on Separate Days: Whenever possible, schedule mutually exclusive procedures on separate days or in different settings. This ensures that each procedure is performed when medically necessary and reduces the risk of denials under code 231.
3. Ensure Accurate Coding: Double-check the coding of procedures to ensure accuracy. Use the appropriate codes for each procedure and verify that they are compatible and can be performed together according to the insurance company’s guidelines.
4. Document Medical Necessity: Clearly document the medical necessity for performing multiple procedures in the same day/setting. Include detailed notes in the medical records that explain the reasons for combining the procedures and how they contribute to the patient’s overall treatment plan.

5. Example Cases

Here are two examples of denial code 231:

• Example 1: A patient undergoes a knee arthroscopy and a knee replacement on the same day. Since these procedures are considered mutually exclusive, the insurance company denies the claim under code 231.
• Example 2: A patient receives a colonoscopy and an upper endoscopy during the same visit. The insurance company determines that these procedures should not be performed together and issues a denial under code 231.

Source: Claim Adjustment Reason Codes