Denial reason code CO/PR B7
We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?
Provider was not certified/eligible to be paid for this procedure/service on this date of service.
You received this denial, because the date of service on the claim is prior to the provider’s Medicare effective date, or after his/her termination date, or because you are billing for a procedure code beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.
Submit claims for services rendered when the provider had active Medicare billing privileges.
Review the Medicare Remittance Advice (RA), and verify the date of service.
• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date.
Note: The effective date can be retroactive, 30 days from receipt of application, or for a future date of up to 60 days after receipt of application.
• If you require additional assistance, you may contact Provider Enrollment.
Submit claims for laboratory services within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification.
• Refer to the complete list of downloads of Categorization of Tests on the Centers for Medicare & Medicaid Services (CMS) website.
• Refer to the List of Waived Tests from the CMS website to determine which codes require the modifier QW (CLIA waived tests).
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.
Or, if applicable, request a telephone reopening. Note: The First Coast Service Options Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
Denial reason code CO 97
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 codes (RARCs) noted on the remittance advice and then refer to the specific resources/tips outlined below, as applicable, to avoid this denial.
M15 – Separately billed services/tests have been bundled as they are considered components of that same procedure. Separate payment is not allowed.
• The service billed was already paid as part of another service/procedure for the same date of service. Payment for this service is always bundled into payment for other service(s) not specified. Separate payment is never made.
An example of a “bundled service” is a telephone call from a hospital nurse regarding a patient. Another example is procedure code A4550, surgical tray.
• Check the procedure code.
M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.
• 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 of a surgery, 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 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.
• Ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.
• Always check beneficiary eligibility prior to submitting claims to Medicare.
• The services billed are subject to consolidated billing requirements by the Home Health Agency (HHA), while the beneficiary is under a home health plan of care authorized by a physician. The HHA is responsible for providing these services, either directly or under arrangement.
