Railroad Medicare denial

Denials: Top Reasons and Procedures

The Palmetto GBA Denial Finder tool includes resources for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you pick up the phone.

• Access denial reasons in plain language
• Scroll through the titles to locate your procedure
• Use the Palmetto GBA search engine to search by remark code

Following are five of the top reasons that services submitted to Palmetto GBA are denied:

• The patient is enrolled in hospice care. Services of the patient’s designated attending physician and services that are unrelated to the patient’s terminal condition may be paid separately, but modifiers are required to note these exceptions
•  'Noncovered services' - these services are never covered, including eye refraction, 'well person' exams, and hot/cold packs used in physical therapy
• Bundling due to 'Correct Coding Initiative' - services denied most often for these reasons include: pulse oximetry; heparin; creatinine (blood); and some supplies
• Medicare is secondary, but the claim was submitted as primary. The MSP Lookup Tool can help guide you as to whether another insurer may be involved.
• Pre- and post-op visits are included in the global surgery package. Tip: access the CMS Medicare Physician Fee Schedule Database (MPFSDB) to determine the global period for surgical procedures. The Palmetto GBA Modifier Lookup tool provides step-by-step instructions for accessing the MPFSDB as well as guidance on how to submit 'exceptions' to the global surgery package.

Posted in: Denial and action,Rail Road Medicare