OCT

Most common denial and how to avoid denials

How To Prevent The Most Common Prepayment Errors

We ask providers in all specialties and states to evaluate the information and resources below and verify
you are taking the necessary steps to prevent future errors.

The errors fell into four categories:

1. We did not receive the requested documentation within the requested 45 days. We denied these
claims.

Please evaluate the procedures in your office for responding to Medicare and/or the Comprehensive
Error Rate Testing (CERT) contractor requests for documentation. When the physician office does not
supply the needed documentation, there is no evidence the physician performed the service. The
physician office is responsible for supplying documentation to support the services he/she billed to
Medicare.

2.Services not documented in the medical records. This fell into two categories. We denied these claims.

Documentation received was for another service. When returning documentation based on a request
from WPS Medicare and/or CERT, please verify that the name of the patient, date of service, and service
match the request. It only takes a few moments and may prevent an error and a denial or a request for
repayment.

The provider's signature was missing.

3. Documentation did not support the level of service billed. According to Medicare policy, the
documentation contained in the medical record must not only support the medical necessity of the
billed service, but must also support the level of service by documenting the work performed by the
physician. Medicare considers it an error when the service is over or under-coded. We adjusted and
reimbursed the service at the appropriate level based on the documentation received.

Q: We are receiving a denial with claim adjustment reason code (CARC) CO236. What steps can we take
to avoid this denial code?

This procedure or procedure/modifier combination is not compatible with another procedure or

procedure /modifier combination provided on the same day according to the National Correct Coding
Initiative.

A: You are receiving this reason code when the service(s) has/have already been paid as part of another
service billed for the same date of service.

The basic principles for the correct coding policy are:

• The service represents the standard of care in accomplishing the overall procedure;

• The service is necessary to successfully accomplish the comprehensive procedure. Failure to perform
the service may compromise the success of the procedure; and

• The service does not represent a separately identifiable procedure unrelated to the comprehensive
procedure planned.

If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Be sure to
submit only the corrected line. Resubmitting an entire claim will cause a duplicate claim denial

Q: We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to
avoid this denial?

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.
A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the
associated remittance advice remark codes (RARCs) noted on the remittance advice and then refer to
the specific resources/tips outlined below to avoid this denial.

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 already paid as part of another service/procedure for the same date of service.
Payment for this service is always bundled into payment for other service(s) not specified. Separate
payment is never made.

An example of a “bundled service” is a telephone call from a hospital nurse regarding a patient. Another
example is procedure code A4550, surgical tray.

• 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
by appending 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.

• Click here for ways to verify beneficiary eligibility and get home health episode’s start and/or end date,
if applicable.

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

• You may also look up home health provider information, including servicing provider number, by
clicking here zip.gif.

• The services billed are subject to consolidated billing requirements by the Home Health Agency (HHA),
while the beneficiary is under a home health plan of care authorized by a physician. The HHA is
responsible for providing these services, either directly or under arrangement

Q: We are receiving a denial with claim adjustment reason code (CARC) OA18. What steps can we take
to avoid this denial code?

Exact duplicate claim/service

A: You will receive this reason code when more than one claim has been submitted for the same item or
service(s) provided to the same beneficiary on the same date(s) of service.

• The Medicare claims processing systems contain edits which identify exact duplicate claims and
suspect duplicate claims submitted by Physicians and Practitioners. Click here to review article on the
claim system edits regarding duplicate claims and modifiers that may be used, as applicable to identify
repeat or distinct procedures and services on a claim.

Exact duplicate claims

• Claims or claim lines that exactly match another claim or claim line with respect to the following
elements: HIC number, provider number, from date of service, through date of service, type of service,
procedure code, place of service and billed amount

• Claims or claim lines are denied

• Appeal rights

Suspect duplicate claims

• Claims or claim lines that contain closely aligned elements sufficient to suggest that duplication may
be present and, as such, require that the suspect claim be reviewed

• Criteria for identifying vary according to the following: type of billing entity, type of item or service
being billed, and other relevant criteria

• Appeal rights (unless an exact duplicate)

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B
interactive voice response (IVR) system.
• Ensure necessary appropriate modifiers are appended to claim lines if applicable and resubmit the
claim.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines
only.

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-9 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 lookup tool, to determine if a current and draft LCD exists for Medicare covered
procedure codes.
• Before submitting a claim, you may access the LCD 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).

• Refer to the "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes
relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a
service is/is not considered medically reasonable and necessary.

• 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.

Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take
to avoid this denial?

Provider was not certified/eligible to be paid for this procedure/service on this date of service.

A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective
date or after his/her termination date, or when the procedure code is beyond the scope of the
provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is
missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.

• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or
termination date.

• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership
System (PECOS) and confirm provider’s Medicare effective date. Click here external link for more details.

Note: The effective date can be retroactive, 30 days from receipt of application, or for a future date of
up to 60 days after receipt of application.

• If you require additional assistance, you may contact Provider Enrollment.

Submit claims for laboratory services within the scope of the provider’s CLIA certification.

• Verify service/procedure code is listed as approved under the scope of the provider’s certification.

• Refer to the complete list of downloads of Categorization of Tests external link on the Centers for
Medicare & Medicaid Services (CMS) website.

• Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes
require the modifier QW (CLIA waived tests).

• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for
correcting claim errors.

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

You may also look up hospice provider information, including servicing provider number, by clicking here
compressed file.

The following situations require a modifier be applied to the claim prior to submission.
• Modifier GV: Attending physician not employed by, or paid under agreement with, the patient’s
hospice provider

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

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

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

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

Avoiding denial reason code PR 49 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to
avoid this denial?

Routine examinations and related services are not covered.

A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening
procedure, done in conjunction with a routine/preventative exam.

• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M)
services, for routine or screening purposes, such as an annual physical.
• Before submitting a claim, you may access the LCD and procedure to diagnosis lookup tool and search
by procedure and diagnosis codes to determine if the procedure code to be billed is payable for a
specific diagnosis (e.g., if the combination exists in an LCD).

• Refer to "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes related
to services addressed in the local coverage determination (LCD), and the diagnoses for which a service
is/is not considered medically reasonable and necessary.

• Medicare does cover certain preventive services.

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

• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.

Q: We received a denial with claim adjustment reason code (CARC) PR 170. What steps can we take to
avoid this denial?

This payment is denied when performed/billed by this type of provider.

A: This denial is received when services furnished or ordered by a chiropractor are not related to
treatment by means of manual manipulation of the spine to correct a subluxation. Chiropractic services
for treatment by means of manual manipulation of the spine to correct a subluxation are covered by
Medicare. All other services furnished or ordered by a chiropractor are not.

• When billing HCPCS 98940, 98941 and 98942 for services related to active/corrective treatment for
acute or chronic subluxation, a modifier is required. If the claim is submitted without the applicable
modifier, services are considered maintenance therapy, and the claim will deny.