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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 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 including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials 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 & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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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.

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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.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.
Content provided on this page contains outdated information and instruction and should not be considered current. CGS is providing this archived information for research purposes only. This archived section contains previously issued instructions that have since been updated or are no longer applicable for Medicare billing purposes.

Top Five Claim Denials and Resolutions – Evaluation and Management Services Denials

E/M Service: Similar Services from Multiple Providers in the Same Group

The Remittance Advice will contain the following codes when this denial is appropriate.

M86 Service denied because payment already made for same/similar service(s) within set time frame

Resolution/Resources

Claim status should be checked to verify that the denial is not based on previous payment information.   You can determine the status of a claim through the CGS Interactive Voice Response Unit. 

  • Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.
  • When more than one E/M service is provided to the same patient on the same date by more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems.
  • Physicians in the same group practice but who are in different specialties or subspecialties may bill and be paid without regard to their membership in the same group.

If the claim needs to appealed, signed medical documentation should be provided to justify the services that were provided on that date of service.      On appeal, the identification of the providers' subspecialty, when more than one provider from the same group is billing for E/M services to the same patient on the same date, can be helpful in explaining why multiple providers were needed.

Helpful Hints

  • Conduct internal audits of documentation versus code selections, especially for E/M services
  • Review the E/M Documentation Guidelines on the CMS websiteExternal Website

Reference

E/M Services: CCI Bundling Denials

The Remittance Advice will contain the following codes when this denial is appropriate.

M80 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.

Correct Coding Initiative (CCI)

The Centers for Medicare and Medicaid Services (CMS) wanted to develop, promote, and encourage correct coding practices in order to prevent payment that could be given in error.

The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.

There is a tool that will give step-by-step directions on how to identify codes that are processing based on NCCI EditsExternal PDF.

Resolution/Resources

E/M Service: Duplicate Denials

The Remittance Advice will contain the following codes when this denial is appropriate.

CO-18 Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate

Resolution/Resources

Claim status should be checked to verify that the claim duplication is not based on previous payment information.   You can determine the status of a claim through the CGS Interactive Voice Response Unit. 

In most cases, multiple E/M services that are performed on a single date by the same provider must be combined and submitted as a single service.

  • We strongly encourage all providers and their staff members to become familiar with the E/M documentation guidelines, which were developed jointly by CMS and the American Medical Association
  • Conduct internal audits of documentation versus code selections, especially for E/M services.

E/M Service: Global Surgery Denials

The global days of a surgery are determined by CMS. As part of the Medicare Physician Fee Schedule database (MPFSDB)External Website, the codes all include their global information.  Please check the website for any surgical code that might cause your claim to deny. The "global day" field on the physician fee schedule will have the information on global day coverage information. 

If the Global days are: Then:
090 90 Global days - Major surgery with 1 day pre-operative period and 90 day post-operative period included in the fee schedule amount.
010 10 Global days - Minor procedure with pre-operative relative values on the day of the procedure and post-operative relative values during a 10 day post-operative period included in the fee schedule amount. Evaluation and management services on the day of the procedure and during the 10 day post-operative period are generally not payable.
000 1 Global day - Endoscopic or minor procedure with related pre-operative and post-operative relative values on the day of the procedure only included in the fee schedule amount.
XXX Global days does not apply
YYY Carrier determines whether global concept applies and establishes post-operative period, if appropriate at the time of pricing.
ZZZ Indicates add on codes - These codes must be reported with the primary codes, not as stand alone codes.
  • Evaluation and Management Services can be payable according to certain guidelines within a global period.  These are very common errors or denials.  However, verification of the post-operative global days for the services provided and the appropriate diagnosis information will help make sure that any action taken to correct the claim will be approved.
  • The modifiers 24 and 25 are the common modifiers that are used in these situations.  However, they do have guidelines.  Please check the CGS Modifier Tool for further information about the 24 and 25 modifier. 
  • Please Note: When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.

Reference

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