What is the Reason Code 34923?

Reason Code 34923 indicates a specific claims processing issue where a revenue code line on a claim includes a service date that falls within the established dates of Occurrence Span Code (OSC) 77, yet the corresponding units and/or charges for that service are incorrectly reported as covered. This typically signals a discrepancy in how services are categorized and billed, potentially leading to claims rejection or denial.

Understanding the Components of Reason Code 34923

To fully grasp the meaning of this reason code, it's essential to understand its key elements:

• Revenue Code Line: This refers to a specific line item on an institutional claim form (such as the UB-04) that describes the type of service provided (e.g., room and board, ancillary services) and its associated charges. Each revenue code corresponds to a particular service or department within a healthcare facility.
• Service Date: This is the exact date on which a specific healthcare service was rendered to the patient.
• Occurrence Span Code (OSC) 77 Dates: This crucial span code, typically found on institutional claims, designates the "Non-Covered Level of Care" for psychiatric services. It specifies a period of an inpatient stay during which services for psychiatric care are not covered by the payer, often due to exceeding benefit limits or not meeting medical necessity criteria for a covered level of care.
• Units and/or Charges Appear as Covered: This is the core issue. If a service date falls within the period defined by OSC 77 (meaning it's a non-covered period for psychiatric services), then any units or charges associated with that service date should not be reported as covered or reimbursable by the payer. When they appear as covered, it flags an error.

Why Does Reason Code 34923 Occur?

This reason code arises when there's a mismatch between the reported service date's coverage status and its alignment with the designated non-covered psychiatric days. Common scenarios include:

• Billing Error: Services that were provided during a period designated as non-covered (by OSC 77) are inadvertently billed as if they were covered services.
• System Misconfiguration: Automated billing systems may not correctly differentiate between covered and non-covered days, especially when specific span codes like OSC 77 are applied.
• Lack of Benefit Understanding: The billing team may not have a clear understanding of the patient's specific psychiatric benefit limits or when services transition from covered to non-covered status.
• Incorrect Date Entry: Although less common if OSC 77 is applied, incorrect service dates that mistakenly fall within the OSC 77 span could also contribute.

Impact on Claims and Providers

When Reason Code 34923 is triggered, the claim line (or potentially the entire claim) is likely to be rejected or denied by the payer. This leads to:

• Delayed Reimbursement: Providers will not receive payment until the error is corrected and the claim is resubmitted.
• Increased Administrative Burden: Billing staff must investigate the discrepancy, correct the claim, and resubmit it, adding to operational costs.
• Potential for Recoupment: If an incorrectly paid claim with this error is later identified, the payer may seek to recoup the overpayment.

Corrective Actions and Prevention Strategies

To avoid Reason Code 34923 and ensure smooth claims processing, healthcare providers should implement the following strategies:

• Thorough Benefit Verification: Before or at the beginning of a patient's stay, thoroughly verify psychiatric benefit limits, including the number of covered days and any criteria for non-covered levels of care.
• Accurate Application of Span Codes: Ensure that all occurrence span codes, especially OSC 77, are accurately applied to claims, reflecting the true start and end dates of specific service periods.
• Precise Service Date Alignment: Verify that all service dates align correctly with the patient's benefit period and any applied span codes. Services falling within a non-covered span (like OSC 77) must be billed as non-covered.
• Billing System Configuration: Review and optimize billing system rules to automatically flag or prevent the billing of "covered" charges for service dates that fall within non-covered span codes.
• Staff Training: Regularly train billing and coding staff on proper application of span codes, especially for psychiatric services, and the distinction between covered and non-covered services based on patient benefits and payer guidelines.
• Pre-submission Claim Review: Implement a robust claim review process before submission to identify and correct discrepancies related to service dates, revenue codes, and span codes.

By addressing these points, providers can significantly reduce claim denials related to Reason Code 34923, leading to more efficient revenue cycles and improved financial performance.