skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer


This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
Join eNews       En Español
Text Size:
YouTube LinkedIn Email Print
Close
Send a link to this page
[Multiple email addresses must be separated by a semicolon.]
Last Modified: 1/25/2024 Location: FL, PR, USVI Business: Part B

Using web tools to handle top denied claims in your practice

First Coast offers several tools for you to diagnose why your Medicare claims were denied and resources to help you prevent future claims from such a fate. When a claim gets denied, with First Coast’s web tools you can solve many issues without having to call customer service or submit a written inquiry. Review these tips to improve your cash flow and save time by eliminating denied claims from your medical practice.

Handling most common denial codes

First Coast offers these tips and resources to help you avoid and reduce the most frequently occurring claim denials among providers in Florida, Puerto Rico, and the U.S. Virgin Islands.

Denial Code
Description
How to handle
How to prevent
Additional resources

CO-236

National Correct Coding Initiative
NCCI - 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 or workers comp
If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim.

Be sure to submit only the corrected line. Resubmitting an entire claim will cause a duplicate claim denial.
Use First Coast’s NCCI lookup tool to identify when certain codes are subject to the automated prepayment edits.
CMS National Correct Coding Initiative external link home page
First Coast offers this tutorial on how to use the NCCI code tables to prevent denied claims.

OA-18

Duplicate Services
Exact duplicate claim/service
First Coast's claims systems use filters to screen out suspected duplicate claims. Such claims and claim lines are suspended.

First Coast staff then review suspended claims and determine to pay or deny. Your claim may be eligible for a clerical reopening.

Click here for additional information.
Review this article for preventing duplicate claim denials
When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate.

Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item.
Prevent duplicate claims web-based training course external link

Read more about how modifier 59 is used when billing Medicare for distinct services.

How to establish your SPOT account

CO-97

Bundled services
The benefit for this service is included in the payment/allowance for another service or procedure that has already been adjudicated. If the remittance advice remark code includes:

M15 - (Separately billed services or tests have been bundled. Separate payment is not allowed.)

M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.

N70 - The claim dates of service fall within the patient’s home health episode’s start and end dates. Before providing services to a Medicare beneficiary, determine if a home health episode exists.
Review policy indicators for the procedure code through First Coast's fee schedule look up tool.

Review claim status in SPOT. If the claim is eligible for clerical claim reopening, make the appropriate edits within SPOT.
FAQ on CO-97 denial reason code
Review beneficiary eligibility and benefits information in SPOT
Review the policy indicators for this procedure in the fee schedule look up tool
Check beneficiary eligibility on SPOT to determine if they are receiving home health services

Use First Coast's modifier validation tool to confirm relationship between modifiers and procedure codes.
First Coast fee schedule look up tool -

Tips on modifiers -

CMS internet-only manual, Chapter 12, Medicare Claims Processing Manual - Physicians/Nonphysician Practitioners external pdf file

PR B9

Hospice services
Patient is enrolled in hospice.

Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A).

Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
If services provided are not related to the hospice patient’s terminal condition:
• If claim was submitted without modifier GW, apply modifier and resubmit claim.
• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.
With your SPOT account, check beneficiary eligibility before submitting the claim to Medicare.
Use First Coast's modifier validation tool to confirm relationship between modifiers and procedure codes.
First Coast's hospice resources -


List of hospice providers - https://downloads.cms.gov/files/hcris/hosp10-reports.zip compressed file

PR-170

Chiropractic services
This payment is denied when performed/billed by this type of provider.(Chiropractor)
 Medicare does not cover services provided or ordered by a chiropractor that are not related to treatment by means of manual manipulation of the spine to correct a subluxation.
When billing HCPCS 98940, 98941 and 98942 for services related to active/corrective treatment for acute or chronic subluxation, a modifier is required.
Use First Coast's modifier validation tool to confirm relationship between modifiers and procedure codes.

If the claim is submitted without the applicable modifier, services are considered maintenance therapy, and the claim will deny.
 For additional information regarding billing for chiropractic services, review this page.
Chiropractic services documentation checklist
Complete online course for billing Medicare for chiropractic services. Receive 1.5 continuing education credit hours
In addition to these tips for handling most frequently denied claims, First Coast’s provider website offers many useful tools to manage Medicare billing and prevent denied claims. The most frequently-used tools are the Interactive LCD index and fee schedule look up. However, First Coast offers several more online tools to help you save time and get paid more quickly.

SPOT – Secure Provider Online Tool

With SPOT, Medicare providers have several tools available to diagnose, correct, and prevent denied claims. SPOT gives you the ability to view claims status and patient eligibility information online, conduct detailed data analysis at the claim and provider levels, and reopen claims to make clerical corrections on multiple lines. First Coast offers SPOT to providers at no charge.
“The SPOT simplifies the claims reopening process. It makes it 10 times better to go online and find information on my claims and fix it right there. It’s real time. I’m not wasting time on the phone,” said one provider who uses several of First Coast’s web tools to manage Medicare claims.

‘Incident-to’ self-service tool

The purpose of the incident-to self-service tool is to assist providers with understanding the CMS Part B incident-to requirements and to apply the rules to their individual given patient/provider circumstances and to understand documentation requirements.
"Incident-to" services are defined as those services that are provided incident to physician professional services in the physician's office or in a patient's home. Examples may include services supervised by a physician and provided by non-physician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, or clinical psychologists.

Modifier details tool

Using the modifier details tool before you file a claim can help you prevent a claim denial for an invalid combination of procedure codes and modifiers. While the existence of a valid procedure/modifier combination does not necessarily imply Medicare coverage, the tool provides a level of assurance that the coding of a claim may be valid.

Request your personalized PDS report

The top denial codes represent all Part B Medicare providers in Florida, USVI and Puerto Rico. If you would like to see the top denial codes for your medical practice, order a provider data summary (PDS) report through your SPOT account.
The PDS is a free comprehensive billing report that helps identify potential Medicare billing issues through a detailed analysis of billing patterns in comparison with those of similar provider types. This report will assist in enhancing the accuracy and efficiency of your Medicare billing process.
“Getting to the reports is very easy,” says one provider who used the reports to improve the timing of processing claims in their practice from 13 days to three. “It [PDS report] provides a snapshot of the quality of the claims we are filing,” he said.
Here’s a sample of part of the PDS report that highlights top denial codes:
“PDS Request” Denial Message Code Table -- Part B
Click here for instructions on how to access the PDS report through the SPOT.

Other important tools to use to diagnose and prevent denied claims

In addition to the PDS report, First Coast offers other helpful resources on the Improve your billing page and Tools Center.
View these resources to view denial codes and their definitions.
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.