Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?
Routine examinations and related services are not covered.
A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.
• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M) services, for routine or screening purposes, such as an annual physical.
• Before submitting a claim, you may access the LCD and procedure to diagnosis lookup tool and search by procedure and diagnosis codes to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).
• Refer to "Active, Future, and Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
• Medicare does cover certain preventive services.
Make the necessary correction(s) and resubmit the claim, if applicable. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.
• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.
Q: We received a denial with claim adjustment reason code (CARC) PR 170. What steps can we take to avoid this denial?
This payment is denied when performed/billed by this type of provider.
A: This denial is received when services furnished or ordered by a chiropractor are not related to treatment by means of manual manipulation of the spine to correct a subluxation. Chiropractic services for treatment by means of manual manipulation of the spine to correct a subluxation are covered by Medicare. All other services furnished or ordered by a chiropractor are not.
• When billing HCPCS 98940, 98941 and 98942 for services related to active/corrective treatment for acute or chronic subluxation, a modifier is required. If the claim is submitted without the applicable modifier, services are considered maintenance therapy, and the claim will deny.
Routine examinations and related services are not covered.
A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.
• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M) services, for routine or screening purposes, such as an annual physical.
• Before submitting a claim, you may access the LCD and procedure to diagnosis lookup tool and search by procedure and diagnosis codes to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).
• Refer to "Active, Future, and Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
• Medicare does cover certain preventive services.
Make the necessary correction(s) and resubmit the claim, if applicable. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.
• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.
Q: We received a denial with claim adjustment reason code (CARC) PR 170. What steps can we take to avoid this denial?
This payment is denied when performed/billed by this type of provider.
A: This denial is received when services furnished or ordered by a chiropractor are not related to treatment by means of manual manipulation of the spine to correct a subluxation. Chiropractic services for treatment by means of manual manipulation of the spine to correct a subluxation are covered by Medicare. All other services furnished or ordered by a chiropractor are not.
• When billing HCPCS 98940, 98941 and 98942 for services related to active/corrective treatment for acute or chronic subluxation, a modifier is required. If the claim is submitted without the applicable modifier, services are considered maintenance therapy, and the claim will deny.