Last Modified: 7/19/2023
Location: FL, PR, USVI
Business: Part B
Q: We received 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: This denial is received 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 that allows you to search for code pair edits for Medicare services performed on a specific date of service.
If an NCCI associated modifier is clinically appropriate, then apply the appropriate modifier to the minor/column 2 code only.
Effective with date of service July 1, 2019, modifier 59 or subsets may be applied to either the major or minor code for Part B services only. Proper Use of Modifier 59
• 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• 9 – not applicable (code pair no longer valid)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
• 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 the First Coast eNews
for important changes to Medicare policies, informative articles, and upcoming educational events.
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.
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.