Wednesday, October 28, 2015

Action for these Denials - PR B9, CO236, PR 49

How to Avoiding denial reason code PR 49

Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?

Routine examinations and related services are not covered.

A: You received this denial because the service is a routine/preventive exam, or a diagnostic/screening procedure done in conjunction with a routine/preventative exam.

• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M) services for routine or screening purposes, such as an annual physical.

• Before submitting a claim, you may access the Procedure to diagnosis relationship lookup tool to help determine if the procedure code is payable under the specific diagnosis.

• Refer to "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.

• Medicare does cover certain preventive services.

Make the necessary correction(s) and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.

Denial reason code CO236 and Action

What steps can we take to avoid this denial code CO236?

This procedure or procedure/modifier combination is not compatible with another procedure or procedure /modifier combination provided on the same day according to the National Correct Coding Initiative.

 You are receiving this reason code when the service(s) has/have already been paid as part of another service billed for the same date of service.

The basic principles for the correct coding policy are:

• The service represents the standard of care in accomplishing the overall procedure;

• The service is necessary to successfully accomplish the comprehensive procedure. Failure to perform the service may compromise the success of the procedure; and

• The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.

If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Be sure to submit only the corrected line. Resubmitting an entire claim will cause a duplicate claim denial.

Avoiding denial reason code PR B9

Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?

Patient is enrolled in a hospice.

A: You received this denial, because per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A).
Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.

Check beneficiary eligibility prior to submitting claims to Medicare.

The following situations require a modifier be applied to the claim prior to submission.

• Modifier GV: Attending physician not employed by, or paid under agreement with, the patient’s hospice provider

• If the claim was submitted with a GV modifier, check the patient's file to verify that the attending physician is not employed by the hospice provider.

• Modifier GW: Services not related to the hospice patient’s terminal condition

• If the claim was submitted with a GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.

• If the claim was submitted without the appropriate modifier, apply the modifier and resubmit the claim.

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