CO 97 - CO 97 Payment adjusted because this procedure/service is not paid separately.

CO 97 Payment adjusted because this procedure/service is not paid separately.

Explanation:

• The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

Solution :

Denial indicates services billed may have already been submitted as part of another service billed for the same date of service (services were bundled). Please make note of quarterly updates to the National Correct Coding Initiative (CCI) edits .

• The purpose of NCCI edits is to ensure the most comprehensive codes are billed, rather than component parts.

Some services may always be bundled into other services provided or not separately payable. For instance:

• E/M services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.

• Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.

• Extended hours codes (common after-hour codes) are not separately payable in a facility which operates 24-hours a day.

• Special handling, conveyance or transfer of a specimen to a laboratory from a physician's office is not usually separately payable, as this type of "extra" care is considered within the payment fee schedules.

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Reject reason code C7010 / T5052 reason and actions need to take.

Q: We are receiving reject reason code C7010. What steps can we take to avoid this reason code?

Reason Code: C7010
Description : THE EDITED INPATIENT OR OUTPATIENT CLAIM HAS FROM/THRU DATES THAT OVERLAP A HOSPICE ELECTION PERIOD AND IS NOT INDICATED AS TREATMENT OF A NON-TERMINAL CONDITION (CONDITION CODE '07'). OR A MCCD/DMD NOTICE OF ELECTION (89A) FROM DATE OVERLAPS A HOSPICE ELE CTION PERIOD.

A: You are receiving this reason code when the beneficiary was/is enrolled in a hospice election period for the date of service(s).
• Confirm the beneficiary’s eligibility via direct data entry (DDE), interactive voice response (IVR) system, or Secure Provider Online Tool (the SPOT)
• If the information is invalid 
Contact the hospice provider and ask them to submit their last claim for the beneficiary with occurrence code 42 and the date of disenrollment. Once the records are deleted or updated, refile the claim to Medicare
• If the information is valid and the services provided to the beneficiary are related to their terminal condition for hospice services
Refile the claim with the hospice provider listed on the beneficiary’s records
• If the information is valid and the services provided to the beneficiary are not related to their terminal condition for hospice services
Refile the claim with a condition code 07 (treatment of non-terminal condition for hospice patient)

Reject reason code T5052
Q: We are receiving reject reason code T5052. What steps can we take to avoid this reason code?

Reason Code : T5052
Description : THE CENTER FOR MEDICARE AND MEDICAID SERVICES RECORDS INDICATE THE THE BENEFICIARY IS NOT IN FILE. PLEASE VERIFY THE BENEFICIARY'S IDENTIFICATION AND SUBMIT A NEW CLAIM.

A: You are receiving this reason code when the Centers for Medicare and Medicaid Services (CMS) records indicate the beneficiary is not on file. Verify the beneficiary’s Medicare health identification number and resubmit the claim if the patient is eligible for Medicare Part A coverage. 
There are several ways to obtain beneficiary eligibility:
• Users can access eligibility information via direct data entry (DDE) .
• Contact the interactive voice response (IVR) system by calling (877) 602-8816.
• Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
• 270/271 eligibility transactions -- you can obtain eligibility information in a batch format for a number of beneficiaries.
• Confirm the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
Always remember to check with the beneficiary and/or representative for eligibility prior to submitting claims to Medicare. 
There are also a few things you can do when a beneficiary comes to your facility:
• Always obtain a copy of the red, white, and blue Medicare card prior to providing services.
• Ensure the eligibility dates on the card indicate their coverage is currently valid and not expired or a future date.
• Make sure the name on the claim matches the name as it appears on the Medicare red, white, and blue card. Do not use nicknames.
• If everything matches on the Medicare card, the beneficiary should verify eligibility with the Social Security Administration (SSA)

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