Tips to prevent claim adjustment reason code (CARC)s 54NCD or 53NCD

You receive one of these reason codes when the procedure code is billed with an incompatible diagnosis for payment purposes, and the ICD-10 code submitted isn’t covered under an LCD or NCD.

• You receive 54NCD when billed without the GA modifier, making the provider liable.
• You receive 53NCD when billed with the GA modifier, making the beneficiary liable.

You can avoid these reason codes by reviewing and applying all applicable LCDs and NCDs for the services being performed and billed. LCDs and NCDs are medical policies that provide coverage criteria and documentation requirements. NCDs are national policies that apply to all jurisdictions in the Medicare Program and LCDs are local policies that apply to a particular jurisdiction.

How to search for medical policies:

• NCDs: CMS Medicare Coverage Database
  • Search by keyword, code, or document ID
• LCDs: First Coast’s interactive LCD index
  • Search by LCD ID, keyword (title only), or HCPCS code

Tip: Did you know you can refer to our Part A reason code lookup for a description associated with the Medicare Part A reason codes? Enter a valid reason code into the box and click the submit button.