Wiki Aranesp Medicare denial

[chelai17]

We are billing 96372 and J0881 to medicare and they are denying our claims. One is CO97 stating it is bundled and CO151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services? Please assist, I appreciate your help. Thank you

 

[thomas7331]

A bundling denial, CO-97, would indicate that the denied service is inclusive to something else that you have billed for this date of service, which could be either on the same claim or on a separate claim. If there is no other code billed than these two, then I'm not sure what this would have bundled to and you may need to contact the payer to find that out.

The CO-151 denial indicates that the number of units you have billed, either on this one claim or on a range of claims over a given period of time, exceeds the number that is allowed for a patient for that period of time under the payer's policy. I'd recommend starting by verifying that the units you've billed is correct per the documentation of how much drug was administered. If correct, then you'll need to review your Medicare contractor's LCD and/or NCD policies to determine what their limitations are for this drug, and whether or not the dosage given is actually covered under the policy.

 

[chelai17]

A bundling denial, CO-97, would indicate that the denied service is inclusive to something else that you have billed for this date of service, which could be either on the same claim or on a separate claim. If there is no other code billed than these two, then I'm not sure what this would have bundled to and you may need to contact the payer to find that out.

The CO-151 denial indicates that the number of units you have billed, either on this one claim or on a range of claims over a given period of time, exceeds the number that is allowed for a patient for that period of time under the payer's policy. I'd recommend starting by verifying that the units you've billed is correct per the documentation of how much drug was administered. If correct, then you'll need to review your Medicare contractor's LCD and/or NCD policies to determine what their limitations are for this drug, and whether or not the dosage given is actually covered under the policy.

Thank you for your response. Yes i understand the denial code C097 and CO151 my question is after verifying the amount and there is no other sevice rendered that day that is the denial that we got. The patient only has that service and the amount is correct. This is a non chemo patient

 

[trarut]

Did you verify the J0881 MUE? You can only bill a max of 500 units per day. Have you called your MAC to make sure they didn't get the claim twice in error, causing it to duplicate against itself? We have that happen every now and again.

 

[chelai17]

Did you verify the J0881 MUE? You can only bill a max of 500 units per day. Have you called your MAC to make sure they didn't get the claim twice in error, causing it to duplicate against itself? We have that happen every now and again.

Thank you for your response. Yes we verified the unit and its on the allowed units per day. we are not billing it twice and it is not denying as duplicate

 

[trarut]

You don't say one way or another so I have to go back "call your MAC". I'm leaning toward this being a processing error but it's going to require a call to a CSR to have them research further. Sorry I can't be more help.

 

[rachelb117]

Recently, we had in issue in our office were claims were getting submitted twice in one day - this was causing a ton of CO-151 issues. The only other advice i would have is make sure the HGB level is submitted on the claim and is within the parameters, you don't have any other anemia dx's on the claim accept the exact reason you are giving it and they are included on the LCD/NCD. If we have a b-12 deficiency or iron deficiency on the claim, that will cause this to deny.