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 an LCD or 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 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.

References

• CMS IOM Pub. 100-08, Chapter 13-Local Coverage Determinations