About Appeals

How to Avoid Costly Appeals

This table includes helpful information to help avoid costly appeals. Use the initial submission tips and resources to help reduce claim denials and improve revenue cycle workflow issues within your office.

Denial Code – Narrative Initial Submission Tips & Resources
975 – Frequency/MUE

This service has been provided at a frequency that is more than the medically appropriate indication by policy or regulation.
Review the HCPCS billed and see if a NCD, LCD, or MUE has been established for the procedure.
  • If there is a policy in place, review to determine if the procedure meets an exception.
  • If a medically appropriate exception exists, bill the service with an appropriate modifier and/or documentation to support the service.
Review the HCPCS description to make sure its definition allows for how you are attempting to bill.
  • Can the procedure be done multiple times?
  • Is the code definition appropriate for multiple body areas/procedures?
Resources
338 – Duplicate

A claim for the same service, same date of service, by the same provider has been submitted twice. The second submission will deny as a duplicate.
Duplicate claims may not be submitted for the same service.
  • Continuing to submit duplicate claims for the same service may be seen as an abuse to the Medicare program and investigated by the UPIC.
Resources
029 – Information Does Not Support Need for the Service

The service being provided does not meet medical necessity requirements according to the NCD or LCD.
Review the NCD/LCD to determine the coverage criteria and/or the appropriate diagnosis code(s) for coverage.
  • If the service does not meet the coverage criteria or the diagnosis requirement, then submitting an appeal with no new information is not appropriate. You would only submit an appeal if additional documentation was presented that was not available at the time of the initial claim submission.
Resources
984 – Payment Made For Similar Procedure in Set Timeframe

This claim denied because you have billed for another service on the same DOS in which these services cannot both be paid. Primarily, this is seen when two E/M services are billed on the same day, which is excluded per CMS IOM 100-4, Medicare Claims Processing Manual, Chapter 12, Section 30.6.5.
If the same physician, or physicians of the same specialty within a group, have provided multiple E/M services on the same day for a patient, those services must be combined and billed to the highest level of E/M for the services provided. These cannot be billed separately per CMS policy.
  • Submitting an appeal for this type of denial represents abuse to the Medicare program.
Resources
758 – CCI or MUE

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative.
  • Review the CPT/HCPCS codes billed and see if there is a MUE that has been established for the procedure.
  • All procedures rendered on one day by the same group shall be submitted on one claim; not multiple claims.
  • When multiple services are being rendered, use of modifier 76/77 shall be appended to the additional codes all on one claim to avoid duplicate denials.
  • Review the HCPCS description to make sure its definition allows for how you are attempting to bill.
    • Can the procedure be done multiple times
    • Is the code definition appropriate for multiple body areas/procedures?
Resources
931 – MSP: Send to Primary First

This care may be covered by another payer per coordination of benefits.

Our records show that Medicare is your secondary payer.

This claim must be sent to your primary insurer first.
It is the providers’ responsibility to determine if Medicare is primary or secondary payer.
  • To avoid this denial, check to see if your patient is enrolled in another plan before you submit your claim. Research NGSConnex or the IVR for eligibility facts.
  • Make sure that you are looking at the validity indicator within NGSConnex, effective date and termination date. If your date of service falls between those dates you should submit your claim to the other insurance first and make Medicare last.
Resources
776 – Liability No Fault

This injury/illness is the liability of the no-fault carrier.

Claim denied, because no-fault insurance plan has the ongoing responsibility for medicals (ORM).

No-fault insurance plan is responsible for paying this claim.
It is the providers’ responsibility to determine if Medicare is primary or secondary payer.
  • To avoid these type of denials, you can determine if the beneficiaries file indicates if they have other liability coverage that could be primary to Medicare. Access NGSConnex or the IVR for eligibility facts.
  • Make sure that you are looking at the validity indicator within NGSConnex, effective date and termination date. If your date of service falls between those dates you should submit your claim to the other insurance first and make Medicare last.
Resources
778 – Liability Workman’s Comp

Workers' Compensation insurance plan is responsible for paying this claim.

This injury/illness is the liability of Workers’ Compensation.

Claim denied, because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
It is the providers’ responsibility to determine if Medicare is primary or secondary payer.
  • To avoid these type of denials, you can determine if the beneficiaries file indicates if they have a WC coverage that could be primary to Medicare. Access NGSConnex or the IVR for eligibility facts.
  • Make sure that you are looking at the validity indicator within NGSConnex, effective date and termination date. If your date of service falls between those dates you should submit your claim to the other insurance first and make Medicare last.
Resources
438 – Date of Service Filing Limit

The time limit for filing has expired. You may not appeal this decision.
The time limit for filing all Medicare fee-for-service claims is twelve months, or one calendar year from the date services were furnished.
  • You may not appeal claims that deny for late filing; therefore, do not submit appeals, reopenings, or written inquiries for claim timely filing.
Resources
J43 – Procedure/Services Partially or Fully Furnished by Another Provider

Information submitted on claim does not support this many or frequency of services.
These denials occur when the same/different rendering provider performs the same service, same date of service, type of service, procedure code, and modifiers on different claims.
  • When multiple services are being done, ensure that one claim is submitted containing all the appropriate rendering providers, codes and appropriate modifiers (76/77).
  • Review the medically unlikely edits on codes prior to submitting a claim.
Resources
463 – New Patient Code Billed for Established Patient

'New Patient' qualifications were not met. Only one initial visit is covered per specialty per medical group.
On all E/M service claims, NPPs should enter a provider specialty as either Spec. 50 (NP) or Spec. 97 (PA). In addition to that basic claim information, NPPs should enter additional information, identifying the provider sub-specialty in which the service was provided.
  • This sub-specialty information is entered on the electronic claim in the Loop 2300 NTE Segment or in Box 19 of a paper claim.
  • For example, an NPP seeing a patient within the cardiology sub-specialty area would enter Spec. 06 in the Loop 2300, while an NPP seeing that same patient the same day in the psychiatry sub-specialty area would enter Spec. 26.
Resources
976 – Paid or May be Under EGHP- Disability

This care may be covered by another payer per coordination of benefits.

Our records show that Medicare is the secondary payer. This claim must be sent to the primary insurer first.
It is the providers’ responsibility to determine if Medicare is primary or secondary payer.
  • To avoid this denial, check to see if your patient is enrolled in another plan before you submit your claim. Access NGSConnex or the IVR for eligibility facts.
  • Make sure that you are looking at the validity indicator within NGSConnex, effective date and termination date. If your date of service falls between those dates you should submit your claim to the other insurance first and make Medicare last.
Resources
875 – Ambulance Medical Necessity

These are noncovered services because this is not deemed a medical necessity.

The information provided does not support the need for this service.
  • Transport must be medically reasonable and necessary.
  • Covered destination is to a facility is appropriate to render the required care.
  • To avoid medically necessary claim denials, use the NTE segment when submitting initial claims.
  • To avoid duplicate claim rejections: duplicate claim denial may occur if there are two transports in one day. Ambulance suppliers shall use the NTE segment when submitting initial claims.
Resources
CO4 – Payment Included in SNF Qualified Stay

Payment is included in the allowance for a SNF qualified stay.
Payment for services furnished to SNF inpatients can only be made to the SNF.
Providers shall request payment from the SNF rather than the patient for this service.
Some separately payable services include:
  • Physician's professional services.
  • Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services.
  • Certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services.
  • Erythropoietin for certain dialysis patients.
  • Certain chemotherapy drugs.
  • Certain chemotherapy administration services.
  • Radioisotope services.
  • Customized prosthetic devices.
Resources:
433 – Provider Number Not Valid for These Medicare Services

This provider is not certified or eligible to be paid for this procedure on this date of service.

Surgical codes submitted by non-allowed specialty.
Procedures billed by physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy. Certain services for procedures with AS modifier assistant-at-surgery may be authorized and some that may not be authorized.
  • Go to Fee Schedule lookup, select Medicare Physician Fee Schedule Pricing, select Specific to Fee Code, populate the date of service for the procedure, populate the procedure code, select your region, and click Search. From the pricing page, click on (Details), look at the policy indicator for assistant at surgery.
Resources
921 – Medicare Does Not Pay This Service in This Facility

POS is not valid for procedure code.
Service cannot be paid when provided in this location/facility.

Treatment rendered in an inappropriate or invalid place of service.
  • Designating procedure codes with technical and/or professional components.
  • Professional Component (26) modifier assigned to pay for the physician services only.
  • Technical Component (TC) modifier assigned when the physician does not own the equipment or facilities or employs the technician.
  • The TC modifier assigns the facilities used or the equipment used to perform the procedure.
Resources
772 – PT or OT Limit Reached for the Year

Benefit maximum for this time-period or occurrence has been reached.

Payment or partial payment was not allowed for this service, because the yearly limit has been met.

Frequency and duration is not considered to be reasonable and necessary.

Information submitted does not support this level of service or does not support the need for this many services within this period-of-time.
  • Physical therapy services are billed using the GP modifier.
  • Occupational therapy services are billed using the GO modifier.
  • Speech therapy are billed using the GN modifier.
  • Keep a close watch on visit limits and having those discussions with patients who are still in need of therapy after their benefits have been exhausted, planning for that can often keep a patient financially on board with the outlined plan of care.
  • Benefit maximums can be obtain through NGSConnex.
  • For calendar year 2022, the KX modifier threshold amount: (a) $2,150 for PT and SLP services combined, and (b) $2,150 for OT services.
  • For calendar year 2021, the KX modifier threshold amount: $2,110 for PT and SLP services combined, and. $2,110 for OT services.
Resources
605 – Information Provided Does Not Support Need for Services

Benefit maximum for this time-period or occurrence has been reached.

Payment or partial payment was not allowed for this service, because the yearly limit has been met.

Frequency and duration is not considered to be reasonable and necessary.

Information submitted does not support this level of service or does not support the need for this many services within this period-of-time.
  • Keep a close eye on benefit maximums.
  • Benefit maximums can be obtained through NGSConnex.
  • Keep a close watch on visit limits and having those discussions with patients who are still in need of therapy after their benefits have been exhausted, planning for that can often keep a patient financially on board with the outlined plan of care.
  • There is often a broad gap between benefit limitations and the plan of care outlined for a particular patient.
  • For calendar year 2022, the KX modifier threshold amount: (a) $2,150 for PT and SLP services combined, and (b) $2,150 for OT services.
  • For calendar year 2021, the KX modifier threshold amount: $2,110 for PT and SLP services combined, and. $2,110 for OT services.
Resources
012 – Related Care Before and After Surgery Not Allowed

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

The cost of care before and after the surgery or procedure is included in the approved amount for that service.
An E/M service coded with modifier 24 indicates a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is only to be used with an E/M visit.
  • It is not valid when used with surgeries or other types of services.
  • It is not necessary or appropriate, for modifier 24 to be used with tests done in the postoperative period.
  • When using modifier 24, ensure that the patient’s records and ICD-10 codes recorded on the claim clearly indicate that the E/M visit is unrelated to the original procedure.
  • Medicare allows payment for an E/M service performed on the same day as a minor surgical procedure, if all requirements are met.
  • The additional E/M service must be separately identifiable from the surgical procedure and require significant effort above and beyond the usual pre-and post-procedure service routinely required for the procedure.

An E/M service coded with modifier 25 identifies significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.
  • Medical records should document the E/M service to such an extent that, upon review, the extra effort may be readily identifiable.
  • When using modifier 25, the diagnosis may be the same for both the E/M and the surgery/procedure.
An E/M examination code with modifier 57 indicates a visit that resulted in the initial decision to perform a major surgery. Surgeries that have a 90-day follow-up period are considered major surgeries.
  • When coding modifier 57, ensure the patient’s records clearly indicate when the initial decision to perform the surgery was made. Do not use modifier 57 with an E/M performed on the same day as minor surgery.
Resources
924 – Medicare Does Not Pay Assistant Surgeon For This Procedure Procedures billed by physician are subject to the assistant-at-surgery policy. Certain services for procedures with 80, 81 & 82 modifier assistant-at-surgery may be authorized and some that may not be authorized.
  • Go to Fee Schedule lookup, select Medicare Physician Fee Schedule Pricing, select Specific to Fee Code, populate the date of service for the procedure, populate the procedure code, select your region, and click Search. From the pricing page, click on (Details), look at the policy indicator for assistant at surgery.
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Published 12/15/2021