Way to avoid Appeal
Become familiar with Local Coverage Determinations (LCD).
* An LCD is a decision by a Medicare contractor whether to cover a particular item or service. LCDs contain “reasonable and necessary” information and are administrative and educational tools to assist you in submitting correct claims for payment.
* LCDs are located in the Medical Policy Center on the Highmark Medicare Services website.
Become familiar with National Coverage Determinations (NCD).
* The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on §1862(a)(1) of the Act (the “not reasonable and necessary” exclusion) unless otherwise specifically noted.
* NCDs are located on the CMS website.
Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.
* Modifiers provide the means to indicate a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.
* Appropriate modifier scenarios include:
o a service or procedure has both a professional (26) and technical (TC) component
o a service or procedure was performed by more than one physician (77)
o a service or procedure has been increased (22) or reduced (52)
o only part of a service was performed (54 or 55)
o an adjunctive service was performed (59)
o a bilateral procedure was performed (50)
o a service or procedure was provided more than once unusual events occurred (76)
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