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Tuesday, January 3, 2012

PR 119 Benefit maximum for this time period has been reached

(MEDICARE DOES NOT PAY FOR THIS MANY SERVICES OR SUPPLIES)


CO -119 Benefit maximum for this time period or occurrence has been reached.
Check Benefit Information through website/Calls
If NO - Call the carrier and send the claim to reprocess.

PR - 119 Benefit maximum for this time period or occurrence has been reached.
Check Benefit Information through website/Calls
If YES - Then Bill the Patient

Resources/tips for avoiding this denial

Medicare has specific guidelines that apply to certain services, especially laboratory services. The guidelines for these services (including preventive services) may have utilization guidelines which do not allow the services to be covered if they are performed within a specified time frame after a previous service. Hence we have to check with Medicare whether it has been already performed during this time period if yes, we should perform this service and can postpone to after time period ends. For Example some of the preventive Exam only covered once in a year so we could not perform second time in the same year.

Prior to performing a preventive service, if you are unsure if a beneficiary has had a specific preventive service within the utilization guidelines, to determine the patient's eligibility for the current preventive service that you will be rendering. We could get it from during the verification .


Common example

Cardiovascular disease screening and Healthcare Common Procedure Coding System (HCPCS) code 80061 When conducting cardiovascular disease screening, the following HCPCS codes are allowed:

• 80061-- Lipid Panel, which includes

• 82465 -- Cholesterol, serum or whole blood, total

• 83718 -- Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

• 84478 -- Triglycerides

Per the Medicare billing instructions, effective for dates of service January 1, 2005, and later, Part B Medicare administrative contractors (MACs) shall pay for cardiovascular disease screenings once every 5 years (60 months).

A claim submitted for Cardiovascular Disease Screening should contain the following:

• HCPCS codes 80061, 82465, 83718 or 84478, submitted with one of the following ICD-9-CM diagnose codes:

• V81.0 -- Special screening for ischemic heart disease

• V81.1 -- Special screening for hypertension or

• V81.2 -- Special screening for other and unspecified cardiovascular conditions



Tips to correct the denied claim

This denial is usually correct, as utilization is checked against the common working file (CWF) for the patient.

If you have submitted the claim with a GA modifier and have an Advanced Beneficiary Notice (ABN) on file, you may hold the patient financially responsible.

However, if you submitted the claim erroneously without the GA or other modifier, submit your claim for a .



Denial Reason, Reason/Remark Code(s)

PR-119: Benefit maximum for this time period or occurrence has been met

Resolution/Resources

On January 1, 2006, Medicare implemented financial limitations on covered therapy services (therapy caps).  An exception to the therapy cap may be made when a beneficiary requires continued skilled therapy, (in other words, therapy beyond the amount payable under the therapy cap) to achieve his or her prior functional status or maximum expected functional status within a reasonable amount of time. Documentation supporting the medical necessity of those therapy services must be available in the patient's medical record.

Verify whether the patient has exceeded the therapy cap prior to submitting claims to Medicare through the Palmetto GBA eServices tool or Interactive Voice Response (IVR) unit.

Online Verification for Therapy Caps through eServices

All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

Access the introductory article to learn more by selecting the 'Introducing eServices' graphic on the top of any of our contract home pages


Please Note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.


Billing services and clearinghouses should contact their provider clients to gain access to the system

Specific instructions for accessing therapy cap information through eServices are available in the eServices User Manual external link  (PDF, 7.79 MB) 

If the service qualifies as an exception and may be reimbursed over and above the cap, submit HCPCS modifier KX with the service. Documentation in the patient's medical record must support the use of this modifier. 


HCPCS modifier KX must be submitted in addition to HCPCS modifier GN, GO or GP with therapy services when therapy cap meets all guidelines for an automatic exception. HCPCS modifier KX allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.

Also this denial can be for many reason as like below

Annual Benefit Amount Exceeded
Individual Lifetime Visits Exceeded
Benefit Visit Limit Exceeded
Benefit Dollar Limit Exceeded
Covered days exceeds maximum for hospital
Maximum units exceeded for Medical Policy
 062 All FSA dollars were previously paid out.
 13D Benefit of one such service per day. Type of service was exhausted on earlier claim for the same date of service.
 13M Benefit of one such service in 12 consecutive months.
 14M Benefit of one such service in 24 consecutive months. Type of service was exhausted on an earlier date of service.
 15M Benefit of two such services per day. Type of service was exhausted on an earlier claim for the same date of service.
 18D This service is limited to once per lifetime per tooth space.
 23M Benefit of one such service in 3 years.
 28M The $50.00 maximum benefit for prenatel/child birthing classes has been met. Patient responsibility applied.
 45M Inpatient maximum for this condition has been reached.
 79M Maximum benefit has been reached for this type of service.
  822 Payment is provided for cast restorations, porcelain crowns, and/or a prosthetic device once in a four year period.
  824 Payment is provided for a full mouth x-ray (including panographic) once in a two year period.
Last Update: 11/3/11
  825 Payment is provided for a full mouth x-ray (including panographic) once a year.
  827 Payment is provided for cast restorations and porcelain crowns once in a three year period.
  828 Payment is provided for one periodontal recall visit once in a three month period.
  829 Payment is provided for cast restorations, porcelain crowns and/or a prosthetic device once in a five year period.
  833 Payment is provided for prosthetic appliances once in a five year period.
  838 Payment is provided for relines, including conditioners, once in a twelve month period.
  839 Benefit is provided for one rebase in each twelve month period.
  845 Payment is provided for relines, including conditioners, once in a six month period.
  84D Orthodontic service maximum has been met for this benefit period.
  852 Payment is provided for cast restorations, porcelain crowns and/or a prosthetic device once in a seven year period.
  854 Payment is provided for cast restorations and porcelain crowns once in any twelve month period.
  85D Payment is provided for removable complete dentures, removable partial dentures and/or fixed partial dentures once in a 10 year period.
  860 Benefit is provided for topical fluoride once in each six month period.
Last Update: 11/3/11
 8B3 Payment is provided for cast restorations, porcelain crowns and/or a prosthetic device once in a 36 month period.
  8B6  Photographs are a benefit once in a fice year period and limited to a $35.00 maximum.
  8B7 Benefit is limited to Ten (10) in a Twelve (12) month period.
  8D3 Limited to once per visit.
  925 The maximum allowed for services of this type has been reached.
  953 Benefit is Limited to two (2) times per year.
  955 Implant maximum has been met for this benefit year.
  971 Emergency services performed by an out of network provider are linited to a $100.00 maximum benefit.
  9A2 Benefit is 2 prophys per 12 month period. This prophy is the last pay ment for the benefit period; or, the maximum allowed has been reached.
  9A3 Benefit is 2 fluoride per 12 month period. This fluoride is the last payment for the benefit period or the maximum allowed has been reached.
  9A4 The maximum allowed for services of this type has been reached.
  9A5 The maximum allowed for services of this type has been reached.
  9D2 Orthodontic service maximum has been met for this benefit period.
  CG3 Maximum has been met for these services.
Last Update: 11/3/11 
  DP2 The maximum allowed for this type of service has been reached; or, this service is not covered.
  L09 Class III maximum benefit has been met for this benefit year.
  L10 Maximum has been met for these services. No further benefits are available.
  L11 The maximum has been met for durable medical equipment and/or supplies.
  L13 Preventive health care maximum has been met for this benefit period.
  L14 Vision service maximum has been met for this benefit period.
  L15 Chiropractic service maximum has been met for this benefit period.
  L16 Naturopathic service maximum has been met for this benefit period.
  L17 Acupuncture service maximum has been met for this benefit period.
  L18 Alternative care service maximum has been met for this benefit period.
  L19 Rehabilitation service maximum has been met for this benefit period.
  L1A The yearly stoploss has been met. Benefits will be paid at 100% for the remainder of this calendar/plan year.
  L20 Audio service maximum has been met for this benefit period.
  L25 Maximum benefit has been met for this benefit year.
  L26 Orthodontic maximum has been met for this benefit year.
  L27 TMJ maximum has been met for this benefit year.
Last Update: 11/3/11
  L28 Periodontal maximum has been met for this benefit year.
  L40 Infertility service maximum has been met for this benefit period.
  L41 Hospice Home Respite Maximum has been met.
  L42 Mental Health service maximum has been met for this benefit period.
  L43 Chemical Dependency service maximum has been met for this benefit period.
  L44 Combined Mental Health service maximum has been met for this benefit period.
  L45 Combined Chemical Dependency service maximum has been met for this benefit period.
  L46 Physical, Speech, Occupational Therapy service maximum has been met for this benefit period.
  L47 Physical Therapy service maximum has been met for this benefit period.
  L48 Speech Therapy service maximum has been met for this benefit period.
  L49 Occupational Therapy service maximum has been met for this benefit period.
  L50 Family Planning service maximum has been met for this benefit period.
  L51 Private Duty Nursing service maximum has been met for this benefit period.
  L52 Medical Prescription service maximum has been met for this benefit period
  L53 Mental Health and chemical dependency combined counter maximum has been met.
Last Update: 11/3/11
  L54 Sports Therapy service maximum has been met for this benefit period.
  L55 Hearing Aid maximum has been met for this benefit period.
  L56 Hearing exam service maximum has been met for this benefit period.
  L57 Extended care service maximum has been met for this benefit period.
  L58 Home health service maximum has been met for this benefit period.
  L59 Well baby exam maximum has been met for this benefit period.
  L5A Prescription self-injectables annual maximum has been met.
  L5B Ambulance service maximum has been met for this benefit period.
  L5D Skilled nursing facility maximum has been met for this benefit period.
  L5E Acupuncture, naturopath and/or licensed massage therapist service maximum has been met for this benefit period.
  L5F Well child exam maximum has been met for this benefit period.
  L60 Individual medical out of pocket maximum has been met.
  L61 Family medical out of pocket maximum has been met.
  L62  Individual medical out of network out of pocket maximum has been met.
  L63 Family medical out of network out of pocket maximum has been met.
  L64 Individual hospital out of pocket maximum has been met.
  L65 Family hospital out of pocket maximum has been met.
Last Update: 11/3/11
  L66 Individual hospital out of network out of pocket maximum has been met.
  L67 Family hospital out of network out of pocket maximum has been met.
  L68 Individual medical out of pocket maximum has been met for PCP level.
  L69 Family medical out of pocket maximum has been met for PCP level.
  L70 This service limited to one plan per year. Maximum has been met for this benefit period.
  PS2 Exceeds the maximum number of units for this service.
  TR5 Services in excess of benefit maximum.


Hence we could act based on the exact denial reason and we could bill patient, resubmit with Modifier, changing CPTs and do the adjustment.

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