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

NGS would like to remind providers that using adjustment reason code “LN” to submit adjusted 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.

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 you need to add or change a diagnosis code.

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

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. Use the existing process for appeal/reopen for fully denied claims.

Electronic 837 claims	FISS/DDE Provider Online System
Use condition code D9 Add remarks	Enter “LN” in the ‘Adjust Reason Code’ field
Add the diagnosis code (ensuring the diagnosis is appropriate for the beneficiary and supported in medical records)	Use condition code D9 Add remarks
Make the charges and units covered	Add the diagnosis code making sure the diagnosis is appropriate for the beneficiary and supported in medical records
Enter “LN adjust” in the 2300 BILLING NOTE (NTE) segment NTE02 data element where the NTE01 data element equals ‘ADD’	Delete the denied line and reenter charges as covered