How To Fix Denial Code B22 | Common Reasons, Next Steps & How To Avoid It

Denial Code B22 means that the payment for a claim has been adjusted based on the diagnosis. Below you can find the description, common reasons for denial code B22, next steps, how to avoid it, and examples.

2. Description

Denial Code B22 is a claim adjustment reason code (CARC) that indicates the payment for a claim has been adjusted based on the diagnosis. This means that the insurance company has determined that the diagnosis provided does not warrant full payment for the billed service. The payment is adjusted accordingly, resulting in a lower reimbursement amount.

2. Common Reasons

The most common reasons for denial code B22 are:

1. Inadequate Documentation: Insufficient or incomplete documentation supporting the diagnosis can lead to denial under code B22. If the medical records do not provide enough evidence to justify the billed service, the insurance company may adjust the payment accordingly.
2. Incorrect Diagnosis Coding: Errors in coding the diagnosis can result in denial under code B22. If the diagnosis code does not accurately reflect the patient’s condition or does not align with the billed service, the insurance company may adjust the payment based on the correct diagnosis.
3. Lack of Medical Necessity: If the insurance company determines that the billed service is not medically necessary based on the diagnosis provided, they may adjust the payment under code B22. This typically occurs when the diagnosis does not support the need for the specific service or procedure.
4. Uncovered Diagnosis: Some insurance plans have specific exclusions for certain diagnoses or conditions. If the diagnosis falls under an exclusion, the insurance company may adjust the payment under code B22.
5. Upcoding or Downcoding: In some cases, providers may intentionally or unintentionally upcode or downcode the diagnosis to receive higher reimbursement or avoid denials. If the insurance company identifies such discrepancies, they may adjust the payment under code B22.

3. Next Steps

You can address denial code B22 by following these steps:

1. Review Documentation: Thoroughly review the medical documentation to ensure it supports the billed service and diagnosis. If any gaps or deficiencies are identified, work with the healthcare provider to obtain the necessary documentation to justify the service.
2. Verify Diagnosis Coding: Double-check the diagnosis coding to ensure accuracy. If any errors or discrepancies are found, correct the coding and resubmit the claim with the accurate diagnosis code.
3. Provide Additional Information: If the insurance company requests additional information to support the diagnosis, promptly provide the requested documentation. This may include medical records, test results, or physician notes that provide further evidence of medical necessity.
4. Appeal the Denial: If you believe the denial under code B22 was incorrect, you have the option to appeal the decision. Follow the insurance company’s appeal process and provide any additional supporting documentation or arguments to challenge the denial.
5. Seek Clinical Documentation Improvement (CDI) Support: Engage with CDI specialists or consultants who can assist in improving the quality and accuracy of clinical documentation. Their expertise can help ensure that the documentation adequately supports the diagnosis and the billed service.

4. How To Avoid It

To avoid denial code B22 in the future, consider the following steps:

1. Ensure Comprehensive Documentation: Encourage healthcare providers to document all relevant information, including the patient’s condition, symptoms, test results, and treatment plan. Comprehensive documentation helps support the diagnosis and justifies the billed service.
2. Train Coding Staff: Provide training to coding staff to ensure they have a thorough understanding of diagnosis coding guidelines and conventions. Regularly update their knowledge to stay current with any changes or updates in coding practices.
3. Stay Updated on Insurance Policies: Familiarize yourself with the insurance policies and guidelines related to diagnosis coding and medical necessity. This knowledge will help ensure accurate coding and reduce the risk of denials under code B22.
4. Implement Quality Assurance Processes: Establish quality assurance processes to review claims before submission. This includes verifying the accuracy of diagnosis coding and conducting internal audits to identify any potential coding errors or discrepancies.

5. Example Cases

Below are two examples of denial code B22:

• Example 1: A healthcare provider submits a claim for a specialized procedure with a diagnosis code that does not align with the billed service. The insurance company adjusts the payment under code B22, citing lack of medical necessity.
• Example 2: A coding error results in an incorrect diagnosis code being submitted for a claim. The insurance company identifies the error and adjusts the payment under code B22 based on the correct diagnosis.

Source: Claim Adjustment Reason Codes