Medicare denial code CO 50 , CO 97 & B15, B20

Denial code co - 50 : These are non covered services because this is not deemed a "medical necessity" by the payer.

Explanation and solution : It means that Medicare thinks that the submitted procedure not required to perform. Check the DX or submit the claims with Medical records.

Q: We are receiving a denial with claim adjustment reason code (CARC) CO50/PR50. What steps can we take to avoid this denial code?

These are non-covered services because this is not deemed a “medical necessity” by the payer.

“Medical necessity” assures services are reasonable and necessary for the diagnosis or treatment of illness/injury

A: You are receiving this reason code when the procedure code is billed with an incompatible diagnosis, for payment purposes and the ICD-10 code(s) submitted is not covered under a Local or National Coverage determination (LCD/NCD).

• Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD.

• Provides a guide to assist providers in determining whether a particular item or service is covered and in submitting correct claims for payment.

• LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part.

• Refer to LCD and procedure to diagnosis lookup tool, to determine if a current and draft LCD exists for Medicare covered procedure codes.

• Before submitting a claim, you may access the lookup tool and search by procedure and diagnosis to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• Report only the diagnosis(es) for treatment date of service.

• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.

• Diagnosis-related denials can be appealed when your documentation supports that a diagnosis from the LCD would apply to your patient’s treatment condition.

Denial code CO - 97 : Payment is included in the allowance for the basic service/procedure.

Explanation and solution : It means that payment not paid separately. Submit with correct modifier or take adjustment.

 CO-97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

CO-B20 Procedure/service was partially or fully furnished by another provider.

 Common Reason for Message

    This is a duplicate of a charge already submitted.

Next Step

    Verify documentation for the following:
        Service is appropriate to bill
        Is a modifier is required
        Payment was already allowed and/or paid to patient's deductible
    Submit an Appeal request - Items or services with this message have appeal rights
        Indicate services were not duplicate
        Submit documentation with Redetermination request. View Medical Documentation Requirements

Claim Submission Tips

    When billing repeat procedures, append repeat modifier to procedure code
        Most common repeat modifier
            Modifier 76 - Repeat procedure by same physician
            Modifier 77 - Repeat procedure by another physician
            Modifier 91 - Repeat clinical diagnostic lab test

Denial code B15 : Claim/service denied/reduced because this procedure/service is not paid separately.  This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

Explanation and solution : The same as above.

Reason for Denial
When a provider is NON-PAR with the carrier.

Actions for denials

If our Provider is NON PAR with that particular plan we have to check with the Client for further process.
Have to start the Credentialling process for this provider

To avoid this denial in future
We have to initiate or inform the Client prior to the service rendered.
We have to make a setup in Software to Alert the Front Desk Executive. For these scenarios we can check with them for next course of action.

More denial and solutions

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