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Pulmonology Coding Alert

You Be the Coder:

Rejection is Not the End of Claim

Published on Fri Oct 24, 2014

Question: My doctor saw a Medicare patient in the office, and we billed 99214. He wanted spirometry, pre and post and diffusion capacity performed at the same time. I billed 99214 with a modifier 25 and 94060 and 94729 without modifiers, as I have done for years. Now only the visit is being paid for and the tests were declined with a C0-16. Has something changed or this there another modifier that they want us to use now?

Washington Subscriber

Answer: According to the information given, your coding was not incorrect. C0-16 means that the claim/service lacks information or has submission/billing error, which is needed for adjudication. The CO16 denial code alerts you that there is information that is missing in order for Medicare to process the claim. This error submission code should also be accompanied by a Remark Code that lets you know exactly what information is lacking (e.g., Remark Code N26: Mailing/incomplete/invalid referring provider primary identifier). The claim can be re-submitted with the correct information. Do not always assume that the service is missing a modifier, look further into the error code for guidance. Here are some tips from CGS Medicare involving claim submission errors: http://www.cgsmedicare.com/partb/pubs/specman/pdf/SPECMAN_claim_submission_errors.pdf
 
If the guidance is unclear, you should raise the issue with Medicare. You should call the Medicare and speak with a representative to get the information needed to resubmit the claim. 

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