Reason Code: 5ND07
Error Description:
The services are denied because the procedure and diagnosis coding requirements for bariatric surgery have not been met per National Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity
Avoiding/Correcting This Error
- To prevent this error, ensure all Medicare coverage and medical necessity requirements are met prior to billing. Providers can visit the CMS Coverage Database to review the NCDs and LCDs to determine the diagnosis and procedure codes that are covered for the services rendered.
- Review the coverage and billing relevant to NCD 100.1 prior to rendering the services. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Refer to resources in the “Additional Information” section below.
- Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials.
Related Content
- CMS Internet-Only Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 100.1 “Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity”
- MLN Matters® MM10086: ICD-10 Coding Revisions to National Coverage Determinations (NCDs) contains a link to a spreadsheet providing coding updates for NCD 100.1
- See also the CMS ICD-10 website for Links related to ICD-10 NCDs
- NGS Appeals Information on the NGS website and Medicare Parts A & B Appeals Process