How To Fix Denial Code 59 | Common Reasons, Next Steps & How To Avoid It

Denial Code 59 means that a claim has been processed based on multiple or concurrent procedure rules. This denial code is often associated with situations involving multiple surgeries, diagnostic imaging, or concurrent anesthesia. In this article, we will explore the description of denial code 59, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 59 is a claim adjustment reason code (CARC) that indicates a claim has been processed based on multiple or concurrent procedure rules. This means that the insurance company has determined that the services billed fall under the category of multiple surgeries, diagnostic imaging, or concurrent anesthesia. The specific details regarding the application of denial code 59 can be found in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) of the claim, if present.

2. Common Reasons

The most common reasons for denial code 59 are:

1. Multiple Surgeries: Denial code 59 may be triggered when a claim includes multiple surgical procedures performed during the same operative session. Insurance companies have specific guidelines and reimbursement policies for multiple surgeries, and if these guidelines are not followed, the claim may be denied.
2. Diagnostic Imaging: Claims that involve multiple diagnostic imaging procedures, such as X-rays, MRIs, or CT scans, may result in denial code 59. Insurance companies often have restrictions on the frequency or combination of diagnostic imaging tests that can be performed within a certain timeframe.
3. Concurrent Anesthesia: When multiple procedures require anesthesia services to be performed simultaneously, denial code 59 may be applied. Insurance companies have guidelines regarding the appropriate use of concurrent anesthesia and may deny claims that do not meet these guidelines.

3. Next Steps

If you receive denial code 59, follow these next steps to resolve the issue:

1. Review the Claim: Carefully review the claim to ensure that it accurately reflects the services provided and the corresponding procedure codes. Check for any errors or discrepancies that may have triggered the denial.
2. Consult the Healthcare Policy Identification Segment: If the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) is present in the claim, refer to it to understand the specific rules or guidelines that were applied in the processing of the claim. This information can help you identify any non-compliance issues.
3. Contact the Insurance Company: Reach out to the insurance company’s provider support to discuss the denial and seek clarification on the specific reasons behind the application of denial code 59. This communication can help you understand the insurance company’s policies and guidelines better.
4. Provide Additional Documentation: If you believe that the denial was in error or that there are extenuating circumstances that justify the multiple or concurrent procedures, gather any necessary documentation to support your case. This may include medical records, operative reports, or other relevant documentation that demonstrates the medical necessity or appropriateness of the services provided.
5. Appeal the Denial: If you disagree with the denial and have supporting documentation, submit an appeal to the insurance company. Follow their specific appeals process and provide a clear and concise explanation of why you believe the denial should be overturned.

4. How To Avoid It

To avoid denial code 59 in the future, consider the following strategies:

1. Understand Insurance Guidelines: Familiarize yourself with the insurance company’s policies and guidelines regarding multiple surgeries, diagnostic imaging, and concurrent anesthesia. Ensure that you are aware of any restrictions or requirements that may apply.
2. Proper Coding and Documentation: Accurate coding and thorough documentation are crucial to avoid denials. Ensure that the procedure codes accurately reflect the services provided and that the medical records clearly support the medical necessity of the procedures.
3. Verify Coverage and Guidelines: Before performing multiple surgeries, diagnostic imaging, or concurrent anesthesia, verify the patient’s insurance coverage and check for any specific guidelines or requirements that may apply. This proactive step can help you avoid potential denials.
4. Communicate with Patients: Clearly communicate with patients about the procedures being performed, the potential for denials related to multiple or concurrent procedures, and any financial implications they may face. This transparency can help manage expectations and prevent surprises.

5. Example Cases

Here are two examples of denial code 59:

• Example 1: A patient undergoes two separate surgical procedures during the same operative session. The claim is submitted with both procedure codes, but the insurance company applies denial code 59 because the procedures are not eligible for reimbursement as multiple surgeries.
• Example 2: A provider performs an MRI and a CT scan on a patient within a short timeframe. The claim is denied with denial code 59 because the insurance company’s policy restricts the frequency or combination of diagnostic imaging tests.

Source: Claim Adjustment Reason Codes