Submit an Adjustment to Correct Claims Partially Denied by Automated LCD/NCD Denials

NGS would like to reemphasize to providers that using adjustment reason code of “LN” to submit adjustment claims (xx7, xxQ), where changes were made to an LCD/NCD denied line or lines, is acceptable for the denial reason codes below, which includes the 59xxx series of NCD codes. Please review the below notice and cascade to the appropriate staff.                                                                                                             

There are some situations that do not require an appeal. You may initiate an adjustment to a claim that has been partially denied by automated edits for NCDs or LCDs.

If a claim or line item has been denied without medical review, that is, no additional documentation request (ADR) was sent to you and no documentation was submitted, you may correct the claim through the regular electronic claim adjustment process.

Please Note:

• Claims for which these adjustments will be accepted are those with line item denial reason codes 55A00, 55A01, 52NCD, 53NCD, 54NCD, and the 59xxx series.
• The process is designed to allow providers to add diagnosis coding to the claim to justify services that were automatically denied based on lack of an appropriate diagnosis, according to an LCD or NCD.
• The process is to be used only for line items denied for 55A00, 55A01, 52NCD, 53NCD, 54NCD, and the 59xxx series. If a provider needs to appeal/reopen other lines on the same claim that have different denial reason codes, follow the existing process, submitting an adjustment, or a request for reopening/redetermination, as appropriate. See section on how to submit an appeal electronically.
• The process cannot be used to add charges to the claim or change HCPCS codes on denied lines. Follow the existing adjustment or appeal/reopening process for these changes.
• If all lines on the claim were denied (claim status = D), providers cannot adjust the claim through FISS/DDE or by submitting electronically. Use the existing process for appeal/reopen for fully denied claims.