How To Fix Remark Code M24 (RARC) | Common Reasons, Next Steps & How To Avoid It

Remark Code M25 means that the information provided does not substantiate the need for the level of service billed. This code is often used by healthcare providers and insurance companies to indicate that the service rendered was not adequately supported by the documentation provided.

1. Description

Remark Code M25 indicates that the information furnished does not substantiate the need for the level of service billed. The official description states: ‘The information furnished does not substantiate the need for this level of service.’ This remark code is typically used when the documentation provided does not adequately support the medical necessity or appropriateness of the service rendered.

2. Common Reasons

1. Inadequate documentation: The documentation provided may be incomplete, missing key details, or fail to demonstrate the medical necessity of the service.
2. Lack of supporting evidence: The documentation may lack supporting evidence such as test results, diagnostic reports, or other relevant information.
3. Insufficient justification: The documentation may not provide sufficient justification for the level of service billed, such as the complexity or severity of the patient’s condition.
4. Failure to meet criteria: The service rendered may not meet the specific criteria or guidelines set forth by the payer or regulatory bodies.

3. Next Steps

1. Review the documentation: Carefully review the documentation provided to identify any gaps or deficiencies that may have led to the denial or adjustment.
2. Consult with the healthcare provider: Reach out to the healthcare provider to discuss the specific reasons for the denial or adjustment and request any additional documentation or clarification that may be necessary.
3. Appeal the decision: If you believe the service should have been fully covered as billed, you have the option to appeal the decision within the specified timeframe. Follow the payer’s appeal process and provide any additional supporting documentation to strengthen your case.

4. How To Avoid It

1. Ensure comprehensive documentation: Make sure that all relevant information, including the medical necessity and appropriateness of the service, is clearly documented.
2. Include supporting evidence: Attach any necessary test results, diagnostic reports, or other supporting documentation to substantiate the level of service billed.
3. Stay updated with payer guidelines: Familiarize yourself with the specific criteria or guidelines set forth by the payer or regulatory bodies to ensure compliance and avoid potential denials or adjustments.
4. Communicate with the healthcare provider: Maintain open lines of communication with the healthcare provider to address any questions or concerns regarding the documentation requirements.

5. Example Cases

1. Case 1: A claim for a complex surgical procedure is denied because the documentation provided does not adequately justify the need for such an extensive intervention.
2. Case 2: A claim adjustment occurs for a high-level office visit due to insufficient documentation supporting the complexity of the patient’s condition.

Source: Remittance Advice Remark Codes