Check claims status via the SPOT, the Part B interactive voice response (IVR) system or your remittance advice to determine if another claim was paid or is currently being processed.

To prevent duplicate denials, allow 14-29 days to process a claim before resubmitting.

See Tips to prevent CARC OA18 for more information. 

Evaluation and management (E/M) services related to the surgery conducted during the post-op period are considered not payable separately.

If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim.

See Tips to prevent CARC CO 97 for more information.

Bundled services should not be billed to Medicare. The service, procedure or item billed is considered part of a comprehensive service or procedure. 

If the procedure code has a “b” status on the Medicare Physician Fee Schedule (MPFS) database, the service / procedure is not paid separately, not even with a modifier. Do not bill Medicare.

See Tips to prevent CARC CO 97 for examples of bundled services.

For additional details, see the CMS IOM, Pub. Medicare Claims Processing Manual 100-04, Chapter 12, section 20.3.

Check patient eligibility through SPOT prior to submitting claims to Medicare. 

Refer to the patient eligibility and claim status FAQ for options on how to verify patient eligibility and get hospice effective and/or termination date, if applicable.

See Tips to prevent CARC CO B9 for more information.

Records show the procedure code billed indicates the service was routine in nature or is being billed using a routine diagnosis rather than one indicating the diagnosis or treatment is for an illness or injury or to improve the functioning of a malformed body member.

Review the services billed and determine if the most appropriate procedure code and diagnosis was reported.

See Tips to prevent CARC PR 49 for additional information.

For additional details, see the CMS IOM Pub. 100-02, Chapter 16, Sections 20 and 90.

Review the services billed and determine if the most appropriate procedure code and diagnosis was reported.

See Tips to prevent CARC PR 96 for additional information.

Common issues may include an invalid procedure code, or an unlisted or not otherwise classified procedure billed without a claim comment and / or documentation.

Check code status via our Fee Schedule Lookup Tool to confirm the procedure code is valid for Medicare. If the procedure code has an “I” status, the procedure code is not valid for Medicare and should not be billed unless documentation is needed for a secondary payer or supplemental plan.

See Tips to prevent RUC CO 16 for more information.

This reason code is received when a claim is submitted to Medicare, and the patient is enrolled in a Medicare Advantage plan or is covered under a capitation agreement.

A claim for the service(s) in question must be submitted to the Medicare Advantage insurer for processing and payment consideration.

See Tips to prevent RUC CO 24 for more information.

Our records indicate the claim was billed without a performing or rendering provider, the reported performing provider is not associated with the billing group, or the claim was billed using an individual provider's National Provider Identifier (NPI) rather than a billing group.

Validate the rendering / performing provider's NPI. Ensure the NPI is valid and associated with the billing group.

See Tips to prevent RUC CO 16 for more information.

When a medication has not been assigned a CPT or HCPCS code, use a not otherwise classified (NOC) code based on the descriptor. Drug description and dosage must be entered in the narrative field of the claim.

See Appropriate use of not otherwise classified codes for more information.

Claim contains an invalid combination of HCPCS codes and modifiers.

Review your claim to ensure the appropriate modifier was reported on your claim and resubmit.

See Tips to prevent RUC CO4 for more information.