Denial reason code CO236 FAQ
Q: We are receiving a denial with claim adjustment reason code (CARC) CO236. What steps can we take to avoid this denial code?
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.
A: 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.
Please stay up to date with quarterly updates to the National Correct Coding Initiative (NCCI) edits external link
• The purpose of NCCI edits is to ensure the most comprehensive codes, rather than component codes, are billed.
Denial reason code CO 50/PR 50 FAQ
Q: We are receiving a denial with claim adjustment reason code (CARC) CO50/PR50. What steps can we take to avoid this denial code?
These are non-covered services because this is not deemed a “medical necessity” by the payer.
“Medical necessity” assures services are reasonable and necessary for the diagnosis or treatment of illness/injury
A: You are receiving this reason code when the procedure code is billed with an incompatible diagnosis, for payment purposes and the ICD-10 code(s) submitted is not covered under a Local or National Coverage determination (LCD/NCD).
• Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD.
• Provides a guide to assist providers in determining whether a particular item or service is covered and in submitting correct claims for payment.
• LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part.
• Refer to LCD and procedure to diagnosis lookup tool, to determine if a current and draft LCD exists for Medicare covered procedure codes.
• Before submitting a claim, you may access the lookup tool and search by procedure and diagnosis to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).
• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
• Report only the diagnosis(es) for treatment date of service.
• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.
• Be proactive, stay informed on Medicare rules and regulations and maximize the self-service tools on the First Coast website.
• Diagnosis-related denials can be appealed when your documentation supports that a diagnosis from the LCD would apply to your patient’s treatment condition.
Medicare denial codes, reason, remark and adjustment codes.Medicare, UHC, BCBS, Medicaid denial codes and insurance appeal. Sample appeal letter for denial claim. CO, PR and OA denial reason codes codes.
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