Medicare denial code CO 50 , CO 97 & B15, B20, N70, M144, M15

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.

Glycosylated Hemoglobin A1C: Medical Necessity Denials

Denial Reason, Reason/Remark Code(s)

CO-50: These are non-covered services because this is not deemed a 'medical necessity' by the payer

CPT code: 83036


CMS has established national guidelines related to lipid panels as a National Coverage Determination (NCD), which were effective January 1, 2003. The most important step you can take is to check the NCD guidelines before you submit a claim.

NCDs apply to all Medicare fee-for-service contractors and provide a uniform set of instructions for processing claims for these services. NCDs for these tests specify:

Indications: in what circumstances is the test considered 'medically necessary'?

Limitations: in what circumstances is the test contraindicated? Are there frequency parameters for Medicare coverage?

CPT or HCPCS codes included in the NCD

Diagnosis codes covered by the Medicare program

Other Facts about Clinical Laboratory Tests

The complete NCD for hemoglobin A1C tests is available on the CMS website and in the CMS NCDs manual (Pub. 100-03, Part 3, Section 190.21)

Refer to the Medicare NCDs Coding Policy Manual and Change Report for information regarding:

Specific CPT and HCPCS codes included in the NCD

Covered diagnosis codes (part of the 'laboratory edit module')

Diagnosis codes that are 'never covered' for any laboratory NCD

You may also download the entire Lab Code List from this web page

The covered diagnosis code list changes as often as quarterly for these NCDs; the list may differ depending upon the date of service

The diagnosis code reported on the claim must be the most specific code available that accurately reflects the primary reason the test was ordered/performed

The patient's medical record must support the use of the diagnosis code(s) reported on the claim

Certain diagnosis codes are designated as 'never covered' by Medicare

NCDs exist for other clinical laboratory tests

Advance Beneficiary Notice (ABN) Information

Be aware of coverage restrictions before you submit a claim. If Medicare will not cover the test based on the patient's condition, you may ask the patient to sign an ABN. For more information on ABNs, refer to the Beneficiary Notice Initiative page on the CMS website.

ABSs must be issued using the standard CMS form. Access the revised ABN and other background information from the CMS website.

If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool under Self Service Tools for information on HCPCS modifier GA

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

M15 – Separately billed services/tests have been bundled as they are considered components of that same procedure. Separate payment is not allowed.

• The service billed was paid as part of another service/procedure for the same date of service. Separate payment is never made for routinely bundled services and supplies. Bundled services should be billed to Medicare only when a denial is needed for a supplemental or secondary payer.

The following procedures are examples of bundled services commonly seen with this denial.
• 97010: Hot/cold packs
• 99080: Special reports or forms
• 99090: Analysis of clinical data
• Check the procedure code on the First Coast fee schedule lookup tool. Scroll down to policy indicators and review code status. If status is equal to “b,” the service/procedure is not paid separately, not even with a modifier

M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.

• The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery, and conducted during the post-op period of a surgery, are considered not separately payable.

• If billing for split care, coordinate split-care billing activities with other provider(s) involved in the patient’s care, and ensure the surgical code is billed before the services for post-operative care are billed.

• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial.

• Modifier 54: pre-and intra-operative services performed
• Modifier 55: post-operative management services only
• Modifier 56: pre-operative services only

N70 – Consolidated billing and payment applies.

• The claim dates of service fall within the patient’s home health episode’s start and end dates. Before providing services to a Medicare beneficiary, determine if a home health episode exists.

• Ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.

• Always check beneficiary eligibility prior to submitting claims to Medicare

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

1 comment:

Unknown said...

Great information. Keep up it up. Love it

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