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.
• 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
• 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• 9 – not applicable (code pair no longer valid)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
Centers for Medicare & Medicaid Services (CMS)
• Refer to the NCCI Policy Manual for Medicare services, Chapter 1, Section E – (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 – for additional details on correct coding
First Coast Service Options (First Coast)
• Review the National Correct Coding Initiative (NCCI) tutorial – code pair denials – 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 – 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 – 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
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