Wednesday, February 17, 2016

Denials PR 204 and CO N130 code

Denial Reason, Reason/Remark Code(s)

With a valid ABN:

PR-204: This service/equipment/drug is not covered under the patient's current benefit plan

PR-N130: consult plan benefit documents/guidelines for information about restrictions for this service.

Without a valid ABN:

CO-204: this service/equipment/drug is not covered under the patient's current benefit plan

CO-N130: Consult plan benefit documents/guidelines for information about restrictions for this service.
CPT code: 99397 (Status "N" on MPFSDB)


Resolution/Resources

Routine physical exams are never covered by Medicare except under the 'welcome to Medicare physical' or 'initial preventive physical exam' (IPPE) guidelines. For more information on the IPPE, refer to the CMS website for preventive services:


The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient's right to a determination.

If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

Notice of Exclusion from Medicare Benefits Information 

If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets you know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the 'old' Notice of Exclusion from Medicare Benefits (NEMB) language. Use of the revised ABN is optional for services that are excluded from Medicare benefits.

Access the revised ABN and other background information from the CMS website external link .

If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup tool (located under Self Service Tools on the Palmetto GBA Web page) for information on HCPCS modifier GY or GA.


Denial Reason, Reason/Remark Code(s)

•    PR-204: This service/equipment/drug is not covered under the patient's current benefit plan
•    CPT code: 92015

Resolution/Resources

•    Eye refraction is never covered by Medicare
•    The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient's right to a determination.

Notice of Exclusion from Medicare Benefits Notice

•    If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
•    CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the 'old' Notice of Exclusion from Medicare Benefits (NEMB) language. For services provided on or after March, 1, 2009, you must use the revised CMS ABN if you are providing advance notice on non-coverage to a beneficiary. Use of the  revised ABN is optional for services that are excluded from Medicare benefits. Access the revised ABN, and other background information from the CMS website.
•    If you have obtained a valid ABN for excluded services, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup tool for information on HCPCS modifier GY.

E/M Service: Duplicate Denials
Denial Reason, Reason/Remark Code(s)
•    CO-18 - Duplicate Service(s): Same service submitted for the same patient 
Resolution/Resources

First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA Online Provider Services (OPS) tool or by calling the Palmetto GBA Interactive Voice Response (IVR) unit.

Online Claim Status Verification through OPS

•    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 Online Provider Services' graphic at the top of any of our contract Web 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 claim status information through OPS are available in the OPS User Manual (PDF, 3.6 MB)

•    In most cases, multiple E/M services that are performed on a single date by the same provider must be combined and submitted as a single service

•    We strongly encourage all providers and their staff members to become familiar with the E/M documentation guidelines, which were developed jointly by CMS and the American Medical Association

•    Consider using a standardized 'scoring tool' for consistency in applying the E/M documentation guidelines. Palmetto GBA publishes two online E/M scoresheet tools on our website although there are many others from which to choose.

•    Conduct internal audits of documentation versus code selections, especially for E/M services

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