Denial Code 171 (“Provider/facility mismatch”) creates unnecessary payment delays, affecting 8-12% of specialty claims according to recent billing data. This rejection occurs when payers identify discrepancies between provider credentials, facility type, and services rendered, costing practices an average of $63 per claim in rework.
Top 5 Causes of Code 171 Denials
- Place of Service Conflicts (39% of cases)
- Hospital-based services billed as office visits (POS 11 vs 21)
- ASC procedures are incorrectly coded as outpatient
- Credentialing Gaps (27%)
- The provider lacks facility privileges
- Outdated certifications
- Modifier Omissions (18%)
- Missing -26 (professional component)
- Incorrect -TC (technical component) usage
- Facility Certification Issues (11%)
- Unlicensed service locations
- Expired facility certifications
- Duplicate Billing (5%)
- Same service billed by the facility and provider
- Repeated claims for the same DOS
Proven Prevention Strategies
1. Credentialing Compliance Checklist
- Verify current:
✓ State licenses
✓ Facility privileges
✓ Board certifications
✓ Payer enrollments
2. POS Code Accuracy Protocol
- Implement dual verification for:
▶ Physical location documentation
▶ EHR geolocation tagging
▶ Payer-specific POS requirements
3. Modifier Mastery Guide
- Critical pairings:
Hospital settings: -26 for professional component
ASC procedures: -SG mandatory
Technical services: -TC when applicable
When Denials Occur: 3-Step Resolution
- Root Cause Analysis
- Compare the denied claim against the provider credentials
- Audit facility certification documents
- Corrective Action
- Update provider privilege records
- Resubmit with proper modifiers
- Process Improvement
- Implement pre-submission credential checks
- Train staff on specialty-specific billing rules
How Claims Med Solves Code 171 Issues
Our denial prevention system helps practices reduce Code 171 rejections by 82% through:
✓ Automated Credential Tracking – Real-time provider/facility alignment checks
✓ Modifier Intelligence Engine – AI-powered coding recommendations
✓ Denial Predictive Analytics – Flags at-risk claims before submission
Stop losing revenue to preventable denials. Contact Claims Med Today for a free billing audit.