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Last Modified: 5/16/2020 Location: FL, PR, USVI Business: Part B

Denial reason code CO 50/PR 50 FAQ

Q: We received 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: This denial reason code is received when a procedure code is billed with an incompatible diagnosis for payment purposes, and the ICD-10 code(s) submitted is/are not covered under a Local or National Coverage determination (LCD/NCD).
Medicare contractors develop an LCD when there is no NCD or when there is a need to further define an NCD.
LCDs specify the clinical circumstances when a service is considered reasonable and necessary, for the diagnosis or treatment of an 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 or 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 the 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, and stay informed on Medicare rules and regulations, and maximize the self-service tools, available 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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