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Last Modified: 9/13/2018 Location: FL, PR, USVI Business: Part B

Denial reason code CO236 FAQ

Q: We are receiving a denial with claim adjustment reason code (CARC) CO236. What steps can we take to avoid this denial code?
This procedure or procedure/modifier combination is not compatible with another procedure or procedure /modifier combination provided on the same day according to the National Correct Coding Initiative.
A: You are receiving this reason code when the service(s) has/have already been paid as part of another service billed for the same date of service.
The basic principles for the correct coding policy are:
The service represents the standard of care in accomplishing the overall procedure;
The service is necessary to successfully accomplish the comprehensive procedure. Failure to perform the service may compromise the success of the procedure; and
The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.
Purpose:
The purpose of NCCI edits is to ensure the most comprehensive codes, rather than component codes, are billed.
Where can I locate the procedure to procedure (PTP) code pair edits?
The NCCI PTP lookup is a database on the First Coast website, which allows you to search for code pair edits for Medicare services performed on a specific date of service
The quarterly updates are located on the CMS website at National Correct Coding Initiative (NCCI) edits external link
Helpful hints:
If an NCCI associated modifier is clinically appropriate, then apply the appropriate modifier to the minor/column 2 code only
Exception: unless anatomical modifiers are used (such as RT and LT)
Refer to the modifier policy indicator column in the PTP edit tables
0 – modifier not allowed
1 – modifier is allowed
9 – not applicable (code pair no longer valid)
Associated allowed NCCI modifiers that may be used include:
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU
Never append a modifier to solely bypass an NCCI PTP edit
Validate for the appropriate procedure/modifier combination via the Modifier lookup tool
Procedures are to be reported with the most comprehensive CPT code
Stay up to date with the quarterly CMS updates on NCCI page
Subscribe to First Coast eNews for important changes to Medicare policies, informative articles, and upcoming educational events
Educational resources:
Centers for Medicare & Medicaid Services (CMS)
Refer to the NCCI Policy Manual for Medicare services, Chapter 1, Section E external link – (located in the download section on the CMS NCCI edits page) for general correct coding policies and guidelines on proper modifier usage
CMS internet-only manual (IOM), publication 100-04, chapter 12, section 30 external pdf file – for additional details on correct coding
First Coast Service Options (First Coast)
Review the National Correct Coding Initiative (NCCI) tutorial – code pair denials flash file – this tutorial will demonstrate how to determine if a code pair will be denied due to NCCI on the CMS website
For assistance with the NCCI PTP lookup tool, visit the NCCI PTP lookup tutorial flash file – this tutorial will show how to easily search for coding pairs by entering a procedure code and the performing dates of service
First Coast University course titled National Correct Coding Initiative external link – This intermediate level course will explore the methodology associated with correct coding and explain the NCCI Edit, development, and review processes
Click here for instructions on registering for a First Coast University training account if you do not have one
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Source: First Coast 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.