Last Modified: 9/22/2023
Location: FL, PR, USVI
Business: Part B
Q: We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to avoid this denial?
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.
A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark code (RARC) noted on the remittance advice for your claim, and then refer to the specific resources and tips outlined below to prevent the denial.
M15 – Separately billed services/tests have been bundled, as they are considered components of the same procedure. Separate payment is not allowed.
• Bundled services should not be billed to Medicare. There are no relative value units (RVUs) or payment amounts for these procedure codes. 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 should not be billed to Medicare.
Examples of bundled services commonly seen with this denial:
• 97010: Hot/cold packs
• 99080: Special reports or forms
• 99090: Computer data analysis
• Identify bundled services: Check your most frequently billed procedure codes
on the First Coast fee schedule lookup tool
. Scroll down to policy indicators, and review code status. If status is equal to “b,” the service/procedure is not paid separately, not even with a modifier. Do not bill Medicare.
M144 – Pre/post-operative care payment is included in the allowance for the surgery/procedure.
• The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery and conducted during the post-op period are considered not separately payable.
• If billing for split care, coordinate split-care billing activities with other provider(s) involved in the patient’s care, and ensure the surgical code is billed before the services for post-operative care are billed.
• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial.
• Modifier 54: pre-and intra-operative services performed
• Modifier 55: post-operative management services only
• Modifier 56: pre-operative services only
N70 – Consolidated billing and payment applies.
• The dates of service on the claim fall within the patient’s home health episode start and end dates and are subject to the Home Health Agency (HHA) consolidated billing requirements. Since the beneficiary is under a home health plan of care authorized by a physician, the HHA is responsible for providing the services--either directly or under arrangement.
• Before providing services to a Medicare beneficiary, determine if a home health episode exists.
• Ask the beneficiary (or his/her authorized representative) if he/she is receiving home health services under a home health plan of care.
• Always check beneficiary eligibility prior to submitting your claim.
Source: First Coast Education Action Team
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