How To Fix Denial Code 58 | Common Reasons, Next Steps & How To Avoid It

Denial Code 58 (CARC) means that the treatment rendered was deemed inappropriate or invalid based on the place of service. Below you can find the description, common reasons for denial code 58, next steps, how to avoid it, and examples.

2. Description

Denial Code 58 is a Claim Adjustment Reason Code (CARC) that indicates the payer has determined that the treatment provided was not appropriate or valid for the specific place of service. This means that the location where the service was performed does not meet the criteria set by the insurance company for that particular type of treatment. As a result, the claim is denied, and the provider is not reimbursed for the service.

2. Common Reasons

The most common reasons for denial code 58 are:

1. Incorrect Place of Service: One of the main reasons for denial code 58 is when the provider submits a claim with an incorrect place of service code. Each type of treatment is associated with specific codes that indicate where the service was performed. If the code does not match the actual location, the claim will be denied.
2. Out-of-Network Services: Insurance plans often have specific networks of providers that they cover. If the treatment is performed by a provider who is not part of the network, the claim may be denied under code 58. It is important for providers to verify the patient’s insurance coverage and network status before providing services.
3. Inappropriate Facility: Certain treatments require specific facilities or equipment to be performed safely and effectively. If the treatment is provided in a facility that does not meet the necessary requirements, the claim may be denied. Providers should ensure that they have the appropriate facilities and equipment to perform the treatment before submitting a claim.
4. Incorrect Coding: In some cases, the denial may be due to coding errors. If the service is coded incorrectly, it may appear that the treatment was provided in an inappropriate place of service. Providers should review their coding practices and ensure that they are accurately representing the services provided.

3. Next Steps

You can fix denial code 58 as follows:

1. Review Place of Service: First, review the place of service code submitted on the claim. Ensure that it accurately reflects the location where the treatment was provided. If there was an error in the code, correct it and resubmit the claim.
2. Verify Network Status: If the denial was due to the treatment being performed by an out-of-network provider, verify the patient’s insurance coverage and network status. If the patient has out-of-network benefits, provide the necessary documentation to support the claim and resubmit it.
3. Confirm Facility Requirements: For treatments that require specific facilities or equipment, ensure that the facility meets the necessary requirements. If the denial was due to an inappropriate facility, consider referring the patient to a facility that can provide the required services and resubmit the claim with the correct place of service code.
4. Review Coding Practices: If the denial was due to coding errors, review your coding practices and ensure that you are accurately representing the services provided. Make any necessary corrections and resubmit the claim with the correct coding.
5. Appeal the Denial: If you believe that the denial was incorrect or unjustified, you have the option to appeal the decision. Gather any supporting documentation, such as medical records or guidelines, and submit an appeal to the insurance company. Follow their specific appeals process and provide any additional information that may help overturn the denial.

4. How To Avoid It

You can prevent denial code 58 in the future as follows:

1. Ensure Accurate Place of Service Coding: Double-check the place of service code for each claim to ensure that it accurately reflects the location where the treatment was provided. Use the appropriate codes based on the insurance company’s guidelines.
2. Verify Network Status: Before providing services, verify the patient’s insurance coverage and network status. If the patient is out-of-network, discuss the potential out-of-pocket costs and alternative options with the patient.
3. Confirm Facility Requirements: For treatments that require specific facilities or equipment, ensure that your facility meets the necessary requirements. If not, consider referring the patient to a facility that can provide the required services.
4. Regularly Review and Update Coding Practices: Stay up to date with coding guidelines and regularly review your coding practices. Ensure that you are accurately representing the services provided and using the correct codes.

5. Example Cases

Below are two examples of denial code 58:

• Example 1: A provider submits a claim for a surgical procedure performed in an outpatient clinic. However, the place of service code on the claim indicates that the procedure was performed in a hospital. The claim is denied under code 58 because the treatment was not appropriate for the selected place of service.
• Example 2: A provider performs a specialized diagnostic test that requires specific equipment. However, the test is performed in a facility that does not have the necessary equipment. The claim is denied under code 58 because the treatment was not performed in an appropriate facility.

Source: Claim Adjustment Reason Codes