Tuesday, June 8, 2010

Denial claim - CO 97, M15, M144, N70 - Payment adjusted because this procedure/service is not paid separately.

CO 97 Payment adjusted because this procedure/service is not paid separately.

Explanation:

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

Solution :

Denial indicates services billed may have already been submitted as part of another service billed for the same date of service (services were bundled). Please make note of quarterly updates to the National Correct Coding Initiative (CCI) edits external link.

The purpose of NCCI edits is to ensure the most comprehensive codes are billed, rather than component parts.

Some services may always be bundled into other services provided or not separately payable. For instance:

E/M services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.

Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.

Extended hours codes (common after-hour codes) are not separately payable in a facility which operates 24-hours a day.

Special handling, conveyance or transfer of a specimen to a laboratory from a physician's office is not usually separately payable, as this type of "extra" care is considered within the payment fee schedules.

**  Sometime re-billing with Modifier can get paid for this service. Check that possibilities.

If appropriate, resubmit your claim after appending a modifier and/or correcting your procedure code or other details on the claim.



When we get this denial, we have to double confirm with coding edits, if this codes are comes under Inclusive category. If Yes then go ahead and adjust the balance as Inclusive write off. If not we have to append with appropriate modifier and resubmit the claim as corrected claim for reimbursement.


Also find out addition reason code and come to the conclusion for the denial . Additional reason can be.

219-Provider overlap of global days period PEND

382-Global payment allocated WARN Notification of a global payment

524-CPT codes billed include bundled and unbundled CPTs DENY {Billed CPT} Is included as bundled/unbundled for {CPT Bundled Code}


So only possibilities to get reimbursed by using Modifier or ICD which is not related to Global Surgery procedure.


Billing Under Global Surgery

The Medicare approved amount for surgical and some therapeutic or diagnostic procedures includes payment for services related to the surgery and are not separately payable if performed within the global period


Global Periods

 Minor Procedures

** Total global period is either one or eleven days
** Count the day of the surgery and the appropriate number of days (either 0 or 10) immediately following the day of surgery


 Major Procedures

** Total global period is ninety-two days
** Count one day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery 


Included Components
** Pre-operative visits
** Intra-operative services
** Complications following surgery
** Post-surgery pain management
** Anesthesia by surgeon
** Supplies
** Miscellaneous services
** Post-operative visits

Excluded Services

** Initial Evaluation & Management (E/M) service
** Other physicians’ care
** Unrelated visits/surgeries
** Complications with return to operating room
** Return to operating room
** Unrelated Critical care 
** Staged/distinct procedures
** Diagnostic tests/procedures

Resources 

•    Before you submit a claim for post-surgical E/M services, verify the post-operative period by checking the surgery date and number of follow-up days associated with the surgical procedure 

•    Refer to CPT modifiers 24 and 25 

•    Access complete instructions for documenting and submitting CPT modifier 24 and 25 on the Modifier Lookup.


Additional Modifiers May Apply

When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.

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



How to resolve the denial

1. Check whether it has been billed under global period of the surgery.
2. Add addition Modifier and resubmit the claim

Denial reason code CO 97 FAQ

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 code (RARC) 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 paid as part of another service/procedure for the same date of service. Separate payment is never made for routinely bundled services and supplies. Bundled services should be billed to Medicare only when a denial is needed for a secondary payer.

The following procedures are examples of bundled services commonly seen with this denial.

• 94760: Noninvasive oximetry
• 97010: Hot/cold packs
• 99071: Educational supplies
• 99080: Special reports or forms
• 99090: Analysis of clinical data
• 99100: Special anesthesia services
• A4500: 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 with a modifier

http://medicare.fcso.com/Fee_lookup/fee_schedule.asp


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. 



Bundled Services/Supplies


There are a number of services/supplies that are covered under Medicare and that have HCPCS codes, but they are services for which Medicare bundles payment into the payment for other related services. If carriers receive a claim that is solely for a service or supply that must be mandatorily bundled, the claim for payment should be denied by the carrier.

A.Routinely Bundled

Separate payment is never made for routinely bundled services and supplies. The CMS has provided RVUs for many of the bundled services/supplies. However, the RVUs are not for Medicare payment use. Carriers may not establish their own relative values for these services.

B.Injection Services

Injection services (codes 90782, 90783, 90784, 90788, and 90799) included in the fee schedule are not paid for separately if the physician is paid for any other physician fee schedule service rendered at the same time. Carriers must pay separately for those injection services only if no other physician fee schedule service is being paid. In either case, the drug is separately payable. If, for example, code 99211 is billed with an injection service, pay only for code 99211 and the separately payable drug. (See section 30.6.7.D.) Injection services that are immunizations with hepatitis B, pneumococcal, and influenza vaccines are not included in the fee schedule and are paid under the drug pricing methodology as described in Chapter 17.

C.Global Surgical Packages

The MPFSDB lists the global charge period applicable to surgical procedures.

D.Intra-Operative and/or Duplicate Procedures

Chapter 23 and §30 of this chapter describe the correct coding initiative (CCI) and policies to detect improper coding and duplicate procedures.

E.EKG Interpretations

For services provided between January 1, 1992, and December 31, 1993, carriers must not make separate payment for EKG interpretations performed or ordered as part of, or in conjunction with, visit or consultation services. The EKG interpretation codes that are bundled in this way are 93000, 93010, 93040, and 93042. Virtually, all EKGs are performed as part of or ordered in conjunction with a visit, including a hospital visit.

If the global code is billed for, i.e., codes 93000 or 93040, carriers should assume that the EKG interpretation was performed or ordered as part of a visit or consultation.

Therefore, they make separate payment for the tracing only portion of the service, i.e., code 93005 for 93000 and code 93041 for 93040. When the carrier makes this assumption in processing a claim, they include a message to that effect on the Medicare Summary Notice (MSN).
For services provided on or after January 1, 1994, carriers make separate payment for an EKG interpretation.

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