Wednesday, September 21, 2016

Denial code CO 197 & N347, N20


CO-197 -Precertification/authorization/notification absent.

Some of the  carriers request to obtaining prior authorization from them before the serivce/surgery.  This may be required for certain specific procedures or may even be for all procedures.  So these are carrier specific and procedure specific.  Please note that it is the responsibility of the Physician/Surgeon and not the patient to obtain the authorization# from the carrier.

When you get a denial from the carrier for this reason, first we need to check the system if any note/alert entry has been made for the patient for the DOS concerned and for the procedure in question. Always verify the entire notes/document since we might have already have it in systme. If we have the PreCerfication/Prior Authization document was scanned or uploaded in the PMS then w ehave to update that and resubmit the claim as corrected claim. But make sure todouble comfirm that it should be for the respective DOS and its valid for the DOS. If a valid auth# is found indicate the same else mention the source file name and pg# of the original file along with the PCP’s name and phone#.

Then call the PCP to get the Authorization, once we received then update and submit the claim for reimbursement.


DUPLICATE 

DENIAL CODE WITH DESCRIPTION:
18 - Duplicate claim/service.

Reason for Denial 

Insurance received the same claim more than one time.
Actions for Denial
Check the system whether the claims has been already paid/denied if  yes ignore the denial or follow the below one.
Check the denial history and resubmission history if we submitted the claim more than once without any changes (same dos, procedure, diagnosis code and doctor.)  please resubmit the claims with necessary changes as corrected claim.
If no payment or denial in the claim, we have to get the original claim status through calling or Online
To avoid this denial in the future

If any correction like append modifier/ICD changes/corrected Referring physician/obtained Auth/Referral/Changes in Units/Changes in Billed Amount we have update the claim as “CORRECTED CLAIM” in software. (CMS 1500-CLAIM NOTE Tab)

REMARK CODES & REASON:

N20 - Service not payable with other service rendered on the same date.

N347 - Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

M86 - Service denied because payment already made for same/similar procedure within set time frame

If we received   “Duplicate” denial with the above remark codes, we have to check the below check points.


Need to check if this same procedure/service was rendered/paid to another provider.
Need to submit with appropriate modifier (76/77) after confirmation with Coding Team. Even for EKG 93010 we get Duplicate denial, since we are billing repeatedly this code with combination of 93010-without modifier, 93010 -59,9310-59&76, 93010-76 (Based on EKG document performed timing) same DOS - Cardiology specialist.

Sunday, September 11, 2016

REMARK CODE N56, CO97 AND N390 , 125


Contractors return as unprocessable services for HCPCS with payment indicator D5 (Deleted/discontinued code; no payment made.) and use the following messages:

• Claim Adjustment Reason Code 181 - Procedure was invalid on the date of service.

•x  RA Remark  N56 - Procedure code billed is not correct/valid for the services billed or the date of service billed.

Contractors shall deny services for HCPCS with payment indicators L1 (Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made.), NI (Packaged service/item; no separate payment made.) or S1 (Service not surgical in nature; and not a radiology service payable under the OPPS, drug/biological, or brachytherapy source.

Contractors return as unprocessable services for HCPCS with payment indicator D5 (Deleted/discontinued code; no payment made.) and use the following messages:

• MSN 16.32 - Medicare does not pay separately for this service.

• Claim Adjustment Reason Code 97 - The benefit for this service is included in the payment allowance for another service/procedure that has already been adjudicated.

• RA Remark - N390 - This service cannot be billed separately.

Contractors shall return as unprocessable services for HCPCS with payment indicators B5 (Alternative code may be available; no payment made.) and use the following messages:

• Claim Adjustment Reason Code - 125 - Submission/billing error.

• RA Remark - M51 - Missing/incomplete/invalid procedure code(s).

• RA Remark – M16 - Alert: Please see our web site, mailings or bulletins for more details concerning this policy/procedure/decision.

Tuesday, September 6, 2016

Remark code N428, 5 and N425, CA96

Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009 

Contractors shall deny services for HCPCS with payment indicators C5 (Inpatient surgical procedure under the OPPS; no payment made.), M6 (No payment made; paid under another fee schedule), U5 (Surgical unlisted service excluded from ASC payment. No payment made.), or X5 (Unsafe surgical procedure in ASC. No payment made. Use the following messages:

• MSN 16.2 - This service cannot be paid when provided in this location/facility.

• RA Remark N428 - Service/procedure not covered when performed in this place of service.

• Claim Adjustment Reason Code 5 - The procedure code/bill type is inconsistent with place of service.




Contractors shall deny services for CPT codes with payment indicators E5 (Surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made.), or Y5 (Non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made.) and use the following messages:

• MSN 16.10 – Medicare does not pay for this item or service.

• Claim Adjustment Reason Code 96 – Non-covered charges.

• RA Remark Code - N425 - Statutorily excluded services.


• RA Remark Code M16 - Alert: Please see our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.

NOTE: Contractors shall assign beneficiary liability for facility charges HCPCS codes billed with ASC payment indicators C5, E5, U5 and X5. 

Thursday, September 1, 2016

ASC denial - N200, M97 AND M15


Contractors shall deny globally billed ancillary services on the ASCFS list if billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages: 

• MSN 16.2 – This service cannot be paid when provided in this location/facility.

• N200 – The professional component must be billed separately

• Claim Adjustment Reason Code 4 – The procedure code is inconsistent with the modifier used or a required modifier is missing. Note Refer to the 835 healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.






Contractors shall deny separately billed implantable devices using the following messages: 
• MSN 16.32 – Medicare does not pay separately for this service.

• RA Remark Code M97 - Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.


• RA Remark Code M15 - Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed;

• RA Remark Code MA 109 - Claim processed in accordance with ambulatory surgical guidelines.

• RA Remark Code M16 - Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision.(contractor discretion)

If there is a related, approved surgical procedure for the billing ASC for the same date of service, also include the following message:

• MSN 16.8 - Payment is included in another service received on the same day.

Sunday, August 28, 2016

ASC denial code N95, MA 109 AND M97


Contractors shall deny services not included on the ASC facility payment files (ASCFS and ASC DRUG files) when billed by ASCs (specialty 49) using the following messages:

• Claim Adjustment Reason Code 8 - The procedure code is inconsistent with the provider type/specialty.

• RA Remark Code N95 - This provider type/provider specialty may not bill this service.

• MSN 26.4 - This service is not covered when performed by this provider.





If there is no approved ASC surgical procedure on the same date for the billing ASC in history, contractors shall return pass-through device claims/line items, brachytherapy claims/line items, drug code (including C9399) claims/line items, and any other ancillary service claims/line items such as radiology procedure claim/line items on the ASCFS list or ASCDRUG list as unprocessable using the following messages:

• Claim Adjustment Reason Code 16 - Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remark codes whenever appropriate.

• RA Remark Code MA 109 - Claim processed in accordance with ambulatory surgical guidelines.


• RA Remark Code M16 - Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision (at contractor discretion).







Contractors shall deny the technical component for all ancillary services on the ASCFS list billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages:

• MSN 16.2 – This service cannot be paid when provided in this location/facility.

• Claim Adjustment Reason Code 171 - Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

• Remittance Advice Remark Code M97 – Not paid to practitioner when provided in this place of service. Payment included in the reimbursement issued the facility.

• Remittance Advice Remark Code M16 – Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision (at contractor discretion).

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