Denial reason code CO 236

Facebook Question About CO 236:

“Hi All!
Medicare denial received, paid all CPT except the Re-Eval We billed 97164, 97112, 97530, 97535 – they denied 97164 for CO 236 Any help on corrected billing to get this paid is appreciated!
Thank you!”

Medicare Physical Therapy CPT Code 97164 Triggers Denial Code CO 236 When Billed with Other Procedures

“This procedure or procedure/modifier combination is not compatible with another procedure or procedure /modifier combination provided on the same day according to the National Correct Coding Initiative.”

First Coast – Florida Medicare Response

First Coast’s Answer: This denial is received when the service(s) has/have already been paid as part of another service billed for the same date of service.

The basic principles for the correct coding policy are

• The service represents the standard of care in accomplishing the overall procedure;
• The service is necessary to successfully accomplish the comprehensive procedure. Failure to perform the service may compromise the success of the procedure; and
• The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.

Examples of how NCCI edits affect real claims:

If a physical therapist performs a re-evaluation due to a significant and unexpected change in a patient’s status and during the same treatment visit the therapist delivers two units of CPT Code 97110 therapeutic exercise and one unit of CPT Code 97530 therapeutic activity the re-evaluation CPT Code 97164 will not be paid if a 59 modifier is not added to that specific line item.

Another example might be an occupational therapist who performs a re-evaluation for a patient who was hospitalized between outpatient therapy visits. The OT may deliver CPT code 97168 along with two units of CPT Code 97530 and one unit of CPT Code 97110.

Again, in this case the OT would need to add a 59 modifier to the CPT Code 97168 line item to avoid the NCCI Edits.

Helpful Hints from Florida Medicare

Where can I locate the procedure to procedure (PTP) code pair edits?

• The NCCI PTP lookup is a database on the First Coast website that allows you to search for code pair edits for Medicare services performed on a specific date of service.
• Quarterly updates are located on the CMS website at National Correct Coding Initiative (NCCI) edits

Helpful hints:

• If an NCCI associated modifier is clinically appropriate, then apply the appropriate modifier to the minor/column 2 code only. Effective with date of service July 1, 2019, modifier 59 or subsets may be applied to either the major or minor code for Part B services only. Proper Use of Modifier 59 external link
• Exception: unless anatomical modifiers are used (such as RT and LT)