Friday, November 20, 2015

Diagnostic Cardiology Services: Medical Necessity Denials & EKG, EKG Rhythm Strip and Cardiac Echography: NCCI Bundling Denials


Diagnostic Cardiology Services: Medical Necessity Denials

Denial Reason, Reason/Remark Code(s) 
CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD
CPT codes: 93307, 93320, 93325

Resolution/Resources 

Refer to the 'Transthoracic Echocardiography' Local Coverage Determination
If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an Advance Beneficiary Notice (ABN) prior to performing these tests
ABN Information
ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'
If you utilize ABNs, they must be issued in advance. Maintain a copy in the patient's medical record. Provide the patient with a copy of the signed notice.
ABNs must be issued using the standard CMS form. Access the revised ABN and other background information from the CMS website.
If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool, which is located under Self Service tools, for information on HCPCS modifier GA.

EKG, EKG Rhythm Strip and Cardiac Echography: NCCI Bundling Denials

Denial Reason, Reason/Remark Code(s) 

M-80: Not covered when performed during the same session/date as a previously processed service for the patient
CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
CPT code: 93010, 93042 and 93320

National Correct Coding Initiative

The National Correct Coding Initiative (NCCI) packages or 'bundles' reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resources 
Check NCCI edits prior to claim submission; edits are updated quarterly
Use the Palmetto GBA NCCI tool to determine if the service you are submitting is bundled with another service
CPT codes 93010 and 93042 are bundled with many CPT codes including Percutaneous Transluminal Coronary Angioplasty (PTCA), many diagnostic procedures and some other EKG codes
CPT code 93320 is bundled with various codes including CPT codes 93306, 93307, 93308 and 93018
If these services are separate, distinct services and are marked with indicator '1' in the NCCI edit list, submit CPT modifier 59. Examples of separate, distinct services include situations in which the rhythm strip was taken at a different patient encounter. Supporting documentation is required in the medical records.


For additional, specific information on modifiers that may be used to denote exceptions to NCCI (including CPT modifier 59).

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