How To Fix Denial Code 236 | Common Reasons, Next Steps & How To Avoid It

Denial Code 236 means that a claim has been denied because the procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/fee schedule requirements. In this article, we will provide a description of denial code 236, 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 236 cases.

2. Description

Denial Code 236 is a specific Claim Adjustment Reason Code (CARC) that indicates a claim has been denied due to incompatibility between procedures or procedure/modifier combinations provided on the same day. This denial is based on guidelines set forth by the National Correct Coding Initiative (NCCI) or workers compensation state regulations/fee schedule requirements. Essentially, the insurance company will not reimburse for services that are deemed incompatible or not allowed to be billed together.

2. Common Reasons

The most common reasons for denial code 236 are:

1. Incompatible Procedure Combinations: Denial code 236 often occurs when healthcare providers submit claims for procedures or procedure/modifier combinations that are not allowed to be billed together according to the NCCI or workers compensation state regulations/fee schedule requirements. This could be due to overlapping or conflicting services that are considered medically unnecessary or duplicative.
2. Incorrect Coding: Errors in coding can lead to denial code 236. If the procedures or procedure/modifier combinations are not accurately coded or documented, it may result in claims being flagged as incompatible and subsequently denied.
3. Lack of Documentation: Insufficient or incomplete documentation can also trigger denial code 236. If the necessary documentation to support the medical necessity or appropriateness of the billed procedures is missing, the claim may be denied based on the assumption of incompatibility.
4. Non-Compliance with State Regulations or Fee Schedule Requirements: Workers compensation claims may be denied under denial code 236 if the billed procedures or procedure/modifier combinations do not comply with the specific regulations or fee schedules set by the state. It is crucial for providers to stay updated on these requirements to avoid denials.

3. Next Steps

To resolve denial code 236, follow these next steps:

1. Review the Denial Explanation: Carefully review the explanation provided with the denial code to understand the specific reason for the denial. This will help identify the incompatible procedures or procedure/modifier combinations that need to be addressed.
2. Verify Coding Accuracy: Double-check the coding for the procedures or procedure/modifier combinations in question. Ensure that the codes accurately reflect the services provided and are in compliance with the NCCI guidelines or workers compensation state regulations/fee schedule requirements.
3. Gather Supporting Documentation: Collect all relevant documentation that supports the medical necessity and appropriateness of the billed procedures. This may include medical records, physician notes, test results, and any other evidence that validates the need for the services provided.
4. Submit an Appeal: Prepare a well-documented appeal letter that explains why the procedures or procedure/modifier combinations should be considered compatible. Include the supporting documentation gathered in the previous step to strengthen your case. Submit the appeal to the insurance company for reconsideration.
5. Follow Up: Keep track of the appeal process and follow up with the insurance company to ensure that your appeal is being reviewed. Be prepared to provide any additional information or clarification that may be requested.
6. Seek Expert Assistance: If you encounter challenges in resolving the denial or navigating the appeals process, consider seeking assistance from coding experts or professional billing consultants who specialize in handling denials and appeals.

4. How To Avoid It

To avoid denial code 236 in the future, consider the following tips:

1. Stay Updated on Coding Guidelines: Regularly review and stay updated on the NCCI guidelines or workers compensation state regulations/fee schedule requirements to ensure accurate coding and billing practices.
2. Use Compatible Procedure Combinations: Familiarize yourself with the list of compatible procedure combinations provided by the NCCI or workers compensation state regulations/fee schedule requirements. Ensure that the procedures or procedure/modifier combinations billed together are allowed and supported by the guidelines.
3. Thorough Documentation: Maintain thorough and detailed documentation for all procedures performed. This includes documenting the medical necessity, the relationship between procedures, and any other relevant information that supports the appropriateness of the billed services.
4. Regular Audits: Conduct regular internal audits to identify any coding errors or potential issues with procedure combinations. This proactive approach can help catch and rectify any discrepancies before claims are submitted.

5. Example Cases

Here are two examples of denial code 236:

• Example 1: A healthcare provider submits a claim for both a diagnostic imaging procedure and a surgical procedure performed on the same day. However, according to the NCCI guidelines, these two procedures are considered incompatible and cannot be billed together, resulting in denial code 236.
• Example 2: In a workers compensation claim, a provider bills for a procedure that is not included in the fee schedule set by the state. As a result, the claim is denied under denial code 236 due to non-compliance with the state’s regulations.

Source: Claim Adjustment Reason Codes