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Last Modified: 7/15/2015 Location: FL, PR, USVI Business: Part B

CO/PR 119

Benefit maximum for this time period has been reached
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 that do not allow the services to be covered if they are performed within a specified timeframe after a previous service.
Prior to performing a preventive service, if you are unsure if a beneficiary has had a specific preventive service within the utilization guidelines, contact First Coast Service Options' Inc. (First Coast's) Part B Provider Contact Center to determine the patient's eligibility for the current preventive service that you will be rendering.
Take advantage of the Secure Provider Online Tool (SPOT), where you can view claims status, eligibility and benefits, payment information, and comparative billing data in a secure online environment. The SPOT is an easy way to obtain utilization information for beneficiaries.

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
Click here for additional information on preventive services
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 redetermination.
Source: The Centers for Medicare & Medicaid Services (CMS) Internet-only manual (IOM) Pub 100-04, chapter 18, Section 100 external pdf file
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Source: First Coast Provider Outreach and Education

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.