Denial code 174 is when the service was not prescribed before it was delivered.
Denial code 174 is used when a healthcare service or treatment was not prescribed by a healthcare provider before it was delivered to the patient. This means that the service or treatment was provided without the necessary authorization or approval from a healthcare professional. As a result, the claim for reimbursement may be denied by the insurance company or payer.
Common causes of code 174 are:
1. Lack of proper documentation: One of the common causes of code 174 is the absence or inadequate documentation of the prescription for the service prior to its delivery. This could include missing or incomplete information about the ordering physician, the date of the prescription, or any other relevant details required for proper billing.
2. Delay in obtaining the prescription: Sometimes, healthcare providers may fail to obtain the necessary prescription in a timely manner, resulting in a denial with code 174. This could occur due to administrative errors, miscommunication, or delays in the prescribing process.
3. Incorrect or invalid prescription information: Another cause of code 174 could be the submission of incorrect or invalid prescription information. This may include errors in the ordering physician's name, incorrect dates, or missing details that are essential for proper billing and reimbursement.
4. Failure to meet specific requirements: Certain services may have specific requirements that need to be met before they can be billed. If these requirements are not fulfilled, it can result in a denial with code 174. This could include obtaining prior authorization, meeting specific medical necessity criteria, or following specific guidelines set by payers.
5. Lack of supporting documentation: In some cases, the denial with code 174 may occur due to a lack of supporting documentation. This could include missing or incomplete medical records, progress notes, or other relevant documentation that substantiates the medical necessity of the service and the need for a prescription.
6. Communication breakdown: Communication breakdowns between healthcare providers, patients, and payers can also lead to denials with code 174. This could occur when the prescription is not properly communicated or documented, leading to confusion or disputes during the billing and reimbursement process.
It is important for healthcare providers to address these common causes and ensure that proper protocols are in place to prevent denials with code 174. This includes implementing effective documentation practices, improving communication channels, and staying updated on payer requirements and guidelines.
Ways to mitigate code 174 include ensuring that all services are properly prescribed prior to delivery. This can be achieved by implementing a robust system for documenting and tracking prescriptions. Providers should establish clear communication channels with referring physicians to ensure that all necessary documentation is obtained before delivering the service. Additionally, regular training and education sessions for staff members can help reinforce the importance of obtaining prescriptions and following proper protocols. By proactively addressing this issue, providers can significantly reduce the occurrence of code 174 denials.
The steps to address code 174 (Service was not prescribed prior to delivery) are as follows:
1. Review the medical documentation: Carefully examine the patient's medical records to determine if there is any evidence of a prescription for the service in question. Look for any notes, orders, or other documentation that clearly indicate the need for the service.
2. Consult with the ordering provider: If there is no clear documentation of a prescription, reach out to the ordering provider to gather more information. Contact them directly to discuss the situation and inquire about any missing or overlooked documentation. Document the conversation and any additional information provided by the ordering provider.
3. Obtain a retroactive prescription: If it is determined that a prescription was indeed required but not obtained prior to the service delivery, work with the ordering provider to obtain a retroactive prescription. This may involve submitting a request for the provider to complete and sign a prescription form, clearly indicating the date of the original request.
4. Document the rationale: In cases where a retroactive prescription is obtained, it is crucial to document the rationale for the delay in obtaining the prescription. This may include any extenuating circumstances or reasons for the oversight. Clear and detailed documentation will help support the claim during any potential audits or reviews.
5. Submit a corrected claim: Once the retroactive prescription is obtained and the documentation is in order, submit a corrected claim to the insurance payer. Ensure that all necessary information, including the retroactive prescription, is included with the claim. Follow any specific guidelines or requirements provided by the payer for submitting corrected claims.
6. Monitor the claim status: Keep a close eye on the status of the corrected claim to ensure it is processed correctly. Follow up with the insurance payer if necessary to address any delays or issues that may arise during the processing of the claim.
By following these steps, healthcare providers can effectively address code 174 and work towards resolving any denials related to services not being prescribed prior to delivery.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
