Eli's Hospice Insider

Published on Fri Jan 14, 2011 PDF

You got a little Christmas present from HHH MAC subcontractor National Government Services. As of Dec. 27, NGS allows providers to initiate their own adjustments to claims that have been fully or partially denied by automated edits for national coverage determinations (NCDs) or local coverage determinations (LCDs), NGS notes in an e-mail message to providers. Previously, providers had to submit a written request to NGS for the MAC to make the adjustments.

Why? "Most claims that are denied for reason codes 55A00, 52NCD, 53NCD, or 54NCD involve a diagnosis that meets the requirements of the NCD or LCD and that is appropriately documented in the provider's records," NGS explains. "However, the diagnosis code has been omitted from the claim." The new process will improve efficiency, the MAC says.

Instructions: You should submit adjustments with claim change reason condition code D1, "changes to charges," NGS instructs. Enter the appropriate corrections to the diagnosis or other codes that resulted in the LCD/NCD denial, covered charges for the line item(s) involved, and adjustment reason code "LN" (Provider adjustment to correct LCD/NCD error).