Medicare denial B9 B14 B16 & D18 D21

B9 - Patient is enrolled in a Hospice.

Bill with modifier QW or QV. Please see the below link for more information.


Avoiding denial reason code PR B9 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?

Patient is enrolled in a hospice.

A: Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part  A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.

Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.

http://medicare.fcso.com/faqs/answers/158472.asp

The following situations require a modifier be applied to the claim prior to submission.

• Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:

• Claim should be submitted with modifier GV.

• If claim was submitted with the GV modifier, check patient's file to verify that the attending physician is not employed by the hospice provider.

• Services not related to the hospice patient’s terminal condition:

• Claim should be submitted with modifier GW.

• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.


• If claim was submitted without the appropriate modifier, apply modifier and resubmit claim.



B14 Only one visit or consultation per physician per day is covered.

We cant bill the two consult visit on same day. Check your superbill and correct the information.


B16 'New Patient' qualifications were not met.

Patient will considered new if the doctor never treat him in the past two year otherwise he should be billed as Established patient. Change the code accordingly.


D18 Claim/Service has missing diagnosis information.

D21 This (these) diagnosis(es) is (are) missing or are invalid

Check the diagnosis.

Medicaid denial
Medicare billing
Medicare copay and coins
Medicare place of service

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