Top Tobacco Counseling Claim Errors

Reason Code(s)	Description	Avoiding/Correcting This Error
OA-18	A duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the: same beneficiary; for the same item(s) or service(s); for the same date(s) of service. If more than one claim is submitted for the same item for the same date of service, the second claim will be denied as duplicate. This can occur even if the original claim is in a processing status waiting to be paid.	Ensure that billed claim and/or service is not a duplicate to another claim and/or service previously submitted and processed. Verify the status of service you are billing for before submitting. You can determine the status of a claim through the NGSConnex portal or by calling the NGS IVR. Check the patient history to make sure payment has not been received. Electronic Claim Submitter Tips: Check your EDI validation report to verify your claims were received and accepted or which claims may have been rejected. If you are unsure how to check these reports, contact the EDI Help Desk at 877-273-4334. Don’t set up your claims software system to automatically rebill Medicare claims. Ensure that your claims batching process is functioning properly. RA Tips: Pay close attention to your RA to determine if the denied claim(s) should be resubmitted or appealed. Make sure that your billing staff or third-party billing service knows the Medicare Payment Floor standards.
CO-16	Claim/service lacks information which is needed for adjudication. Claim/service lacks information or has submission/billing error(s) This item or service was denied because information required to make payment was missing. M51: Missing/incomplete/invalid procedure code(s). M76: Missing/incomplete/invalid diagnosis or condition. M81: You are required to code to the highest level of specificity. MA112: Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides. N822: Missing procedure modifier(s).	This service was rejected due to missing and/or invalid information submitted on the claim. The missing and/or invalid information could be a number of issues. You will want to refer to the remark code from the remittance advice in order to determine what piece of information was missing and/or invalid. Please review the annual CPT and HCPCS manual(s) to ensure the claim is coded correctly. Once this is determined you may submit a new claim with the corrected information for that procedure code. Note: rejected claims do not have any appeal rights.
CO-04	The procedure code is inconsistent with the modifier used or a required modifier is missing. Claim was filed with a procedure code and modifier that did not correspond. N519: Invalid combination of HCPCS modifiers.	Modifiers are two-digit codes used to report additional information used during claims processing. Modifiers may be alpha-alpha, alphanumeric or numeric-numeric. Modifiers are used to modify payment of a procedure code, assist in determining appropriate coverage or otherwise identify the detail on the claim. The use of modifiers becomes more important every day when reporting services to ensure appropriate reimbursement from Medicare. These codes should be entered in Item 24D of the CMS-1500 claim form, adjacent to the CPT/HCPCS code reported. CPT modifiers are published in the physicians CPT manual; HCPCS modifiers are reported in the physicians HCPCS manual. For a listing of available modifiers that providers may use when filing claims for Medicare Part B reimbursement, visit Medicare Topic: Modifiers. For accurate claim processing, when appropriate, modifiers must be reported on the claim.
CO-50	These are noncovered services because this is not deemed a `medical necessity' by the payer. This claim has been denied without reviewing the medical/dental record because the requested records were not received or were not received timely. M16: Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision. M64: Missing/incomplete/invalid other diagnosis. N386: This decision was based on a NCD. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at CMS’ Medicare Coverage Database. If you do not have web access, you may contact the contractor to request a copy of the NCD.	Verify that the diagnosis code supports the procedure code. If there are no diagnosis codes for nicotine dependence this could cause the claim to deny for not Medically Necessary. To review specific coverage determination for Counseling to Prevent Tobacco use, please visit CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Part 4. Section 210.4.1.
CO-97	Benefit included in pymt/allowance for another service that has already been adjudicated/pymt included in another service on the same day. M80: Not covered when performed during the same session/date as a previously processed service for the patient. N20: Service not payable with other service rendered on the same day. N386: This decision was based on a NCD. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at CMS’ Medicare Coverage Database. If you do not have web access, you may contact the contractor to request a copy of the NCD.	Research your patient claim history. The HCPCS/CPT that is denied with this error is denied because another service has already been paid for the same date of service. The billing staff of the provider may need to do an intensive search for the paid claim. Review the claim submission to ensure the correct CPT/HCPCS was entered; or If there was a clerical error and the incorrect CPT/HCPCS was entered then you would need to make the correction through a reopening request.
CO-119	Benefit maximum for this time period or occurrence has been reached/ These services cannot be paid because your benefits are exhausted at this time. MA13: Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR group code. N362: The number of Days or Units of Service exceeds our acceptable maximum. N386: This decision was based on a NCD. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at CMS’ Medicare Coverage Database. If you do not have web access, you may contact the contractor to request a copy of the NCD.	This denial could be a couple of different benefit exhausted issues. The best way to prevent any benefit exhaust, at the provider responsibility level, is to ensure you use the NGSConnex portal to verify if the patient has reached their maximum benefit of the service/procedure provided to them. If the benefit maximum shows in NGSConnex, your administrative staff should be discussing with the patient that Medicare may not cover the service, and the patient will need to sign an ABN that states they will be held liable for noncovered charges. To review specific coverage determination for Counseling to Prevent Tobacco use, please visit CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Part 4. Section 210.4.1.
CO-151	Payment adjusted because the payer deems the information submitted does not support this many/frequency of services/ The information provided does not support the need for this many services or items within this period of time.	Checking Medicare eligibility can help avoid this type of denial. There may be other providers the beneficiary has seen that may provide tobacco counseling for same/other dates of service.
CO-236	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.	CMS developed the NCCI to promote national correct coding methodologies and to eliminate improper coding. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. The Medicare NCCI includes edits that define when two HCPCS / CPT codes should not be reported together. A correct coding modifier indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied. A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim using specific NCCI associated modifiers. CCMI of "9," NCCI editing does not apply. To avoid this denial use the Medicare NCCI Procedure to Procedure PTP lookup database to search for code pair edits for Medicare services performed on a specific date of service.
CO-109 OA-109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. This claim/service is not payable under our claims jurisdiction area. We have notified your provider that they must forward the claim/service to the correct carrier for processing. N104: This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website.	This denial is received when your Medicare patient is enrolled in a MA plan. MA Plans are health plans offered by private companies approved by Medicare that replace a beneficiary’s traditional Medicare Plan. When actively enrolled in a MA plan, please submit the Medicare claims to that MA plan. Use the Eligibility option in NGSConnex to verify which MA plan your patient is enrolled with.

Revised 11/8/2024