Creatinine (Blood): NCCI Bundling Denials Code : M80, CO-B15
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: 82565
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. NCCI edits are available at www.cms.gov/NationalCorrectCodInitEd/.
• Use the Palmetto GBA NCCI tool to determine if the service you are submitting is bundled with another service
• CPT code 82565 is bundled with CPT code 80047. CPT code 82565 is also bundled with the following CPT codes: 80048, 80053, 80069 and 82575.
o For these combinations of services, CPT code 82565 is designated with indicator ‘1’ in the CCI edit list. If this is a separate, distinct service, submit CPT modifier 59 to denote it as a separate service.
Examples of separate, distinct services include tests that are performed different patient encounters. Supporting documentation is required in the medical records.
• For additional, specific information on modifiers that may be used to denote exceptions to CCI (including CPT modifier 59), refer to the Palmetto GBA Modifier Lookup tool:
o Jurisdiction 1: Select ‘Articles’ on the left side of the Palmetto GBA Web page
o Ohio, South Carolina and West Virginia: Select ‘Browse by Topic’ on the left side of the Palmetto GBA Web page
Common Reasons for Message
Combination of codes billed on same date of service by same provider may not be appropriately paired together due to National Correct Coding Initiative (NCCI) Edits
Payment for service billed is bundled into payment for another service performed that day
It is unusual for services billed to be performed together
Modifier used to unbundle is on incorrect code or incorrect modifier was used
Next Step
Verify code set is appropriate to be billed together
Submit Appeal request to add modifier, if appropriate
See Appeals webpage for instructions on how to submit a Reopening or Redetermination
Claim Submission Tips
Review NCCI Coding Edits External Link prior to submitting claim to determine if codes are appropriately paired
View How to Use Medicare NCCI Tools External Link
When appropriate, modifier to identify separately identifiable service should be appended to Column 2 code
Modifier Indicator “0” – there are no circumstances in which both procedures of a code pair should be paid; modifier is not allowed for NCCI purposes
Modifier Indicator “1” – modifiers associated with NCCI are allowed with this code pair when appropriate
Modifier Indicator “9” – NCCI edit does not apply to this code pair; edit for code pair was deleted retroactively
Providers may not bill patient for NCCI edit denials
Denial is based on incorrect coding
Providers should not complete an ABN for NCCI edits
Chest X-ray or EKG: Duplicate Denials
Denial Reason, Reason/Remark Code(s)
M-80, 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
CPT codes: 93010, 71010, 71020
Resolution/Resources
First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA eServices tool or by calling the Palmetto GBA Interactive Voice Response (IVR) unit.
Online Claim Status Verification through eServices
All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
Billing services and clearinghouses should contact their provider clients to gain access to the system
Specific instructions for accessing claim status information through eServices are available in the eServices User Manual external link (PDF, 5.73 MB)
Instructions
Submit multiple ‘identical’ services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, use CPT modifier 76 and specify the exact times of each service.
On electronic claims use the documentation record to specify the exact times that each diagnostic service (e.g., chest x-ray, EKG, etc.) was done
On electronic claims use the documentation record to explain why more than one diagnostic service was done on the same date by the same provider
Attachments (e.g., signed radiology reports, signed EKG reports, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., times):
Attachments must be a full page (8 ½ x 11)
On appeal signed medical records (e.g., radiology reports, EKG reports, etc.) may be sent as evidence to show why more than one diagnostic service was billed on the same date by same or similar providers from the same group
Access specific instructions for documenting and submitting CPT modifier 76 through the Palmetto GBA Modifier Lookup. Select ‘Browse by Topic’ on the left side of the Palmetto GBA Web page.
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.
Correct Coding Initiative: The National Correct Coding Initiative (NCCI) packages/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).
Resolution/Resources
Check NCCI edits prior to claim submission; edits are updated quarterly on CMS’ website
Use the Palmetto GBA NCCI tool external link to determine if the service you are submitting is bundled with another service
For specific information on modifiers that may be used to denote exceptions to NCCI (including CPT modifiers 24, 25, 59, 76 and 91), refer to the Palmetto GBA Modifier Lookup tool from the Self Service section on the Palmetto GBA Web page
Is the NCCI indicator ‘0’?
These code pairs will not be reimbursed if submitted for the same date of service. Exceptions to NCCI edits cannot be made for code combinations with an indicator of ‘0’
Is the code indicator ‘1’?
Submit the appropriate modifier to show the service should be separate. Documentation is required in the patient’s medical record. Exceptions to NCCI edits can be made for code combinations with an indicator of ‘1’.
Examples of separate, distinct services include situations in which a bundled service was performed during a different patient encounter