Tuesday, January 13, 2015

Medical Necessity Denials co 50, 57 ,59 , 151 - Diagnostic Cardiology Services:

Denial Reason, Reason/Remark Code(s)

•    CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD

•    Procedure codes: 93307, 93320, 93325

Resolution/Resources

•    Refer to the 'Transthoracic Echocardiography' Local Coverage Determination

•    If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an Advance Beneficiary Notice (ABN) prior to performing these tests
ABN Information

•    ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'

•    If you utilize ABNs, they must be issued in advance. Maintain a copy in the patient's medical record. Provide the patient with a copy of the signed notice.

•    ABNs 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, which is located under Self Service tools, for information on HCPCS modifier GA.

EKG, EKG Rhythm Strip and Cardiac Echography: NCCI Bundling Denials

Denial Reason, Reason/Remark Code(s)


•    M-80: Not covered when performed during the same session/date as a previously processed service for the patient
•    CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
•    Procedure code: 93010, 93042 and 93320

National Correct Coding Initiative


The National Correct Coding Initiative (NCCI) packages or 'bundles' reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resources

•    Check NCCI edits prior to claim submission; edits are updated quarterly

•    Use the Palmetto GBA NCCI tool to determine if the service you are submitting is bundled with another service

•    Procedure codes 93010 and 93042 are bundled with many Procedure codes including Percutaneous Transluminal Coronary Angioplasty (PTCA), many diagnostic procedures and some other EKG codes

•    Procedure code 93320 is bundled with various codes including Procedure codes 93306, 93307, 93308 and 93018

•    If these services are separate, distinct services and are marked with indicator '1' in the NCCI edit list, submit Procedure modifier 59. Examples of separate, distinct services include situations in which the rhythm strip was taken at a different patient encounter. Supporting documentation is required in the medical records.

•    For additional, specific information on modifiers that may be used to denote exceptions to NCCI (including Procedure modifier 59).


Co 151 - Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Action to be taken : Check the coding edits and act accordingly.
Check the units which was billed
Check the level of service billed
 If we billed with correct information then we have to submit the claim with supporting document.



CO 59 - Processed based on multiple or concurrent procedure rules.
Reason and action: This is Multiple surgeries detected, hence confirm with coding guideliness and take the necessity action. Like...to be written off or to bill with appropriate modifier.

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