N97Remark Code (RARC)Active
N97 Remark Code - Exclusion for Specific Conditions
The N97 remark code indicates that the patient is excluded from coverage due to specific conditions such as stress incontinence, urinary obstruction, and certain neurologic diseases. These exclusions apply particularly when secondary manifestations of these conditions are present, which affects the payment for the services billed.
How It Relates to the Denial
The N97 remark code typically accompanies claim adjustment reason codes related to coverage denials based on the patient's specific medical conditions. This combination signals that the payer has determined the services are not covered due to the patient's exclusion criteria.
Common Scenarios
1A claim was submitted for a urological procedure for a patient with a history of stress incontinence and diabetes. The remittance returned with a claim adjustment reason code indicating denial of coverage.
→ In this case, the N97 remark code clarifies that the patient's conditions, specifically stress incontinence and diabetes with peripheral nerve involvement, are reasons for exclusion from coverage for the billed procedure.
2A patient with urinary obstruction and a neurologic condition received treatment for a related symptom. The claim was denied with an adjustment reason code citing lack of coverage.
→ Here, the N97 remark code reinforces the denial by stating that the patient's urinary obstruction and associated neurologic disease fall under the exclusion criteria, impacting the service's eligibility for coverage.
3A claim for a diagnostic test was submitted for a patient diagnosed with stress incontinence and secondary complications. The remittance response included a denial adjustment reason code.
→ The N97 remark code indicates that the patient's diagnosis of stress incontinence, along with any related complications, leads to an exclusion from coverage for the diagnostic test billed.
What to Do
- Review the patient's medical history to confirm the presence of stress incontinence, urinary obstruction, or specific neurologic diseases.
- Verify if the billed services relate directly to the patient's excluded conditions as indicated by the claim adjustment reason code.
- Consider alternate treatment options or services that may be covered based on the patient's current diagnoses.
What to Check
- The patient's medical records for documented conditions related to stress incontinence, urinary obstruction, or neurologic diseases.
- The claim adjustment reason code accompanying the N97 remark to understand the context of the denial.
- Any payer-specific policies regarding coverage exclusions that may apply to the patient's conditions.