Last Modified: 11/23/2017 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
Please use your browser's back button to return to the referring page.
Source: First Coast's Education Action Team
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.