Telehealth has emerged as a critical tool for treating patients with acute respiratory failure, but many healthcare providers face CO-197 denials when billing for these services. CO-197 typically occurs when prior authorization is required but hasn’t been obtained. In this blog, we’ll walk you through how to prevent CO-197 denials for telehealth visits and ensure you’re properly reimbursed for acute respiratory failure treatment.

What is CO-197 Denial Code?

The CO-197 denial code is issued when prior authorization is needed for a physician service, such as a telehealth visit, and the necessary approval has not been obtained. Telehealth services, especially those related to acute respiratory failure or other critical conditions, often require pre-authorization from the patient’s insurance company before the service can be provided and reimbursed.

Without the proper authorization, the insurer will deny the claim under the CO-197 denial code, causing delays in reimbursement.

Why Does CO-197 Denial Happen for Telehealth Visits in Acute Respiratory Failure?

Here’s why CO-197 denials happen, particularly for telehealth visits in acute respiratory failure cases:

1. Lack of Prior Authorization: Many insurance companies require prior authorization for telehealth services, especially for conditions like acute respiratory failure that might involve critical care.
2. Out-of-Network Providers: If the telehealth provider is out-of-network with the patient’s insurer, the claim may be denied, especially if prior approval wasn’t obtained.
3. Mismatched Diagnosis and Treatment: The diagnosis code (e.g., J96.00 – Acute Respiratory Failure) and the telehealth service might not align, resulting in the claim being flagged and denied.

How to Prevent and Overcome CO-197 Denials for Telehealth Visits

Here’s what you can do to prevent CO-197 denials and ensure that your telehealth visits for acute respiratory failure are reimbursed properly:

1. Always Obtain Prior Authorization

Before scheduling a telehealth visit for acute respiratory failure, check if the insurance company requires prior authorization. For critical conditions like respiratory failure, it’s essential to get approval before providing the service.

• Action: Contact the patient’s insurance provider and submit a prior authorization request for telehealth services. Ensure all necessary medical documentation is included for review.

2. Use Correct Diagnosis and Procedure Codes

Ensure the ICD-10 diagnosis code (e.g., J96.00 – Acute Respiratory Failure) matches the CPT code for the telehealth visit. If the codes don’t match or the insurance company determines that the telehealth visit isn’t medically necessary, the claim will be denied.

• Action: Double-check that the ICD-10 codes and CPT codes are correctly aligned with the telehealth treatment being provided. Ensure that acute respiratory failure is accurately coded.

3. Verify In-Network Status for Telehealth Providers

Ensure that the telehealth provider is in-network with the patient’s insurer. If your practice is out-of-network, the insurer may deny the claim unless prior approval is obtained.

• Action: Confirm that the telehealth provider is in-network with the patient’s insurance plan, or contact the insurance provider to confirm whether out-of-network providers can be reimbursed for telehealth services.

4. Appeal the Denial with Complete Documentation

If you receive a CO-197 denial, appeal the decision with comprehensive documentation. Submit the prior authorization request

(if available), the diagnosis code, and any clinical notes that demonstrate the medical necessity of the telehealth visit.

• Action: Submit the appeal along with all required documentation, including medical records, treatment notes, and the prior authorization approval (if applicable).

How ACP Billing Services Can Help

Managing CO-197 denials can be complex, but ACP Billing Services is here to help. We specialize in telehealth billing and have the expertise to ensure that all claims, including those for acute respiratory failure, are handled correctly. With ACP Billing Services, you can:

• Ensure prior authorization is obtained for telehealth visits.
• Use correct coding and documentation to support your claims.
• Appeal denials with the appropriate supporting documentation.
• Streamline your telehealth billing process to avoid delays in reimbursement.

Conclusion

CO-197 denials for telehealth visits related to acute respiratory failure can be challenging, but with the right steps, you can prevent them and get reimbursed for your services. Ensure prior authorization, use accurate codes, and work with ACP Billing Services to streamline your billing process and avoid unnecessary delays.

If you’re facing telehealth billing issues or denial management challenges, contact ACP Billing Services today. We’re here to help you navigate the complexities of telehealth reimbursement and ensure your practice gets paid for the services you provide.

Want to learn more? Let’s discuss your needs on a quick call. Book your appointment now!

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