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Last Modified: 10/17/2018 Location: FL, PR, USVI Business: Part B

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 the "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
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.
Source: CMS IOM Pub. 100-08, Chapter 13-Local Coverage Determinations external.gif
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Source: First Coast's Education Action Team
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