Remark code N718 indicates a claim denial due to missing documentation for a required face-to-face examination.
Remark code N718 is an indication that the claim has been processed with a note that there is missing documentation regarding a face-to-face examination that was required for the service billed.
Common causes of code N718 are incomplete patient records at the time of billing, failure to document the face-to-face examination in the patient's medical chart, documentation not meeting the specific criteria required for a face-to-face examination, or the documentation was not submitted to the payer along with the claim.
Ways to mitigate code N718 include implementing a comprehensive checklist for all patient encounters that specifically includes a reminder for the documentation of face-to-face examinations. Training staff and healthcare providers on the importance of this documentation can also help, emphasizing its role in patient care continuity and billing accuracy. Utilizing electronic health records (EHR) effectively, with built-in prompts or alerts for missing information, can serve as an additional safeguard. Regular audits of patient files to identify and rectify missing documentation before claims submission is another effective strategy. Establishing a clear protocol for the documentation process and ensuring that all healthcare providers are aware of and adhere to this protocol can significantly reduce instances of code N718.
The steps to address code N718 involve a multi-faceted approach to ensure that all necessary documentation, specifically the face-to-face examination records, are accurately and promptly submitted. Initially, it's crucial to review the patient's medical records to confirm if the face-to-face examination was conducted but not documented or if the documentation was not submitted. If the examination was conducted but not documented, reach out to the healthcare provider who performed the examination to obtain the necessary documentation. Ensure that the documentation includes all relevant details such as the date of the examination, findings, and the healthcare provider's signature.
If the documentation was completed but not submitted, prepare and submit a corrected claim with the required face-to-face examination documentation attached. It's essential to follow the specific submission guidelines of the payer to avoid further delays or denials.
In cases where the face-to-face examination was not conducted, schedule the patient for a prompt examination. Following the examination, document the findings thoroughly, ensuring all required information is included, and submit the documentation as part of a corrected claim.
To prevent future occurrences of code N718, implement a checklist for all patient encounters that require a face-to-face examination. This checklist should be part of the patient's pre-appointment preparations and post-appointment documentation review. Additionally, consider training or retraining staff on the importance of documenting all required examinations and on the specific documentation requirements for different types of encounters and payers. Regular audits of patient records can also help identify and rectify documentation gaps before claims are submitted, reducing the likelihood of receiving code N718.
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