• 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
• 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
• 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).
• 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.
Denial reason code CO 50/PR 50 FAQ
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 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.
• Be proactive, stay informed on Medicare rules and regulations and maximize the self-service tools on the First Coast website.
• Diagnosis-related denials can be appealed when your documentation supports that a diagnosis from the LCD would apply to your patient’s treatment condition.