Last Modified: 12/7/2009
Location: FL, PR, USVI
Business: Part B
(DENIED/REDUCED SERVICE/PROCEDURE NOT PAID SEPARATELY)
(PRE/POST OP CARE INCLUDED IN SURGERY. YOU MAY NOT BILL PATIENT)
(SEPARATE PAYMENT NOT MADE FOR THIS SERVICE. DO NOT BILL PATIENT)
Resources/tips for avoiding this denial
Denial indicates service(s) billed has/have already been paid as part of another service billed for the same date of service (services were bundled).
• The purpose of NCCI edits is to ensure the most comprehensive codes, rather than component codes, are billed.
If billing for split-care, be sure to apply appropriate modifiers to surgical codes when billing the services to Medicare. Note: Coordinate split-care billing activities with other providers involved in the patient's care, to ensure the surgical code is billed before post-op care, as this will sometimes cause denial issues.
• Modifier 54 indicates pre- and intra-operative services performed.
• Modifier 55 indicates post-operative management services only.
• Modifier 56 indicates pre-op services only
Some services may always be bundled into other services provided or not separately payable. For instance:
• Evaluation and management (E/M) services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.
• Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.
• Extended hours codes (common after-hour codes) are not separately payable in a facility which operates 24-hours a day (e.g., inpatient/outpatient hospital).
• Special handling, conveyance or transfer of a specimen to a laboratory from a physician's office is not usually separately payable, as this type of "extra" care is considered within the payment fee schedules.
• For an introduction to the National Correct Coding Initiative (NCCI) and associated modifiers, access a replay of our February 10, 2009, Ask-the-contractor webcast
Introduction to the National Correct Coding Initiative -- Part B. This webcast, along with related materials and follow-up questions/answers, can be found in the "Online Resources" section in the "Library" of the
First Coast Service Options (FCSO) Medicare training Web site 
.
• To understand how billing for services or procedures performed in the global period of a surgery can be affected, complete the free Web-based training (WBT) Introduction to Global Surgery -- Part B
• Click here for instructions on registering for our FCSO Medicare training Web site.
Tips to correct the denied claim
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.
• Refer to the
Modifier FAQs on the FCSO Medicare provider Web site for additional information.
Please use your browser's
back button to return to the referring page.
Source: FCSO Education Action Team
for additional details.
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