Remark Code M85 means that the claim is subjected to review of physician evaluation and management services. This code is used to indicate that the services provided by the physician will be carefully evaluated to ensure they meet the necessary criteria for reimbursement. It is important for medical coders to understand the reasons behind this remark code and the steps they can take to address it.
1. Description
Remark Code M85 signifies that the claim is subjected to review of physician evaluation and management services. This means that the services provided by the physician will be carefully assessed to determine if they meet the necessary criteria for reimbursement. The official description of this remark code is ‘Subjected to review of physician evaluation and management services.’ This review process is crucial to ensure that the services rendered are appropriate and medically necessary.
2. Common Reasons
- Inadequate documentation: One of the common reasons for Remark Code M85 is insufficient or incomplete documentation. If the medical records do not provide enough information to support the services billed, the claim may be subjected to review.
- Unbundling of services: Another reason for this remark code is the unbundling of services. If the physician bills for individual components of a service separately instead of using the appropriate bundled code, the claim may be flagged for review.
- Incorrect coding: Coding errors, such as using incorrect codes or modifiers, can also lead to Remark Code M85. If the codes used do not accurately reflect the services provided, the claim may be subject to further evaluation.
- High utilization: Excessive utilization of certain services or procedures may trigger this remark code. If a physician consistently performs a high volume of evaluation and management services, it may raise concerns and prompt a review.
3. Next Steps
- Review the documentation: The first step in addressing Remark Code M85 is to thoroughly review the documentation associated with the claim. Ensure that all relevant information is included and clearly supports the services billed.
- Verify coding accuracy: Double-check the coding to ensure that the correct codes and modifiers are used. It is essential to accurately represent the services provided to avoid triggering a review.
- Provide additional information if necessary: If the documentation is lacking or incomplete, reach out to the physician or healthcare provider to obtain any missing information that may be required for the review process.
- Appeal if appropriate: If you believe that the claim was flagged in error or if you have additional supporting documentation, consider filing an appeal to provide further justification for the services rendered.
4. How To Avoid It
- Ensure comprehensive documentation: To avoid Remark Code M85, it is crucial to maintain thorough and accurate documentation. Include all relevant details, such as the reason for the visit, the services provided, and the medical necessity of those services.
- Follow coding guidelines: Adhere to the official coding guidelines and use the appropriate codes and modifiers for the services rendered. Familiarize yourself with the latest updates and ensure compliance with coding rules.
- Monitor utilization: Keep an eye on the utilization of evaluation and management services to ensure it aligns with industry standards. If there is a significant increase in utilization, investigate the reasons behind it and address any potential concerns.
- Continuing education: Stay updated with the latest coding and documentation requirements through ongoing education and training. This will help you stay informed about any changes that may impact the billing and reimbursement process.
5. Example Cases
- Case 1: A claim for evaluation and management services is subjected to review due to incomplete documentation. The medical coder works with the physician to obtain the necessary information and resubmits the claim with comprehensive documentation, resulting in successful reimbursement.
- Case 2: A claim is flagged for review because the physician consistently bills for a high volume of evaluation and management services. The medical coder conducts an internal audit to ensure the services are appropriately documented and justified, addressing any concerns raised during the review process.
