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Wednesday, June 15, 2016

Coding denial - CO 236 AND CO 50 - Tips to avoid

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.

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