CO 119 & PR 119 – Benefit Maximum for this Time Period has been Reached

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CO 119 - Benefit Maximum for this Time Period has been Reached

 

(MEDICARE DOES NOT PAY FOR THIS MANY SERVICES OR SUPPLIES)

CO -119 Benefit maximum for this time period or occurrence has been reached.

Check Benefit Information through website/Calls
If NO – Call the carrier and send the claim back to reprocess.

PR – 119 Benefit maximum for this time period or occurrence has been reached.

Check Benefit Information through website/Calls
If YES – Then Bill the Patient

Resources/tips for avoiding this denial

Medicare has specific guidelines that apply to certain services, especially laboratory services. The guidelines for these services (including preventive services) may have utilization guidelines which do not allow the services to be covered if they are performed within a specified time frame after a previous service. Hence we have to check with Medicare whether it has been already performed during this time period if yes, we should perform this service and can postpone to after time period ends. For Example some of the preventive Exam only covered once in a year so we could not perform second time in the same year.
Prior to performing a preventive service, if you are unsure if a beneficiary has had a specific preventive service within the utilization guidelines, to determine the patient’s eligibility for the current preventive service that you will be rendering. We could get it from during the verification .

Common example

Cardiovascular disease screening and Healthcare Common Procedure Coding System (HCPCS) code 80061 When conducting cardiovascular disease screening, the following HCPCS codes are allowed:

• 80061– Lipid Panel, which includes

• 82465 — Cholesterol, serum or whole blood, total

• 83718 — Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

• 84478 — Triglycerides

Per the Medicare billing instructions, effective for dates of service January 1, 2005, and later, Part B Medicare administrative contractors (MACs) shall pay for cardiovascular disease screenings once every 5 years (60 months).

A claim submitted for Cardiovascular Disease Screening should contain the following:

• HCPCS codes 80061, 82465, 83718 or 84478, submitted with one of the following ICD-9-CM diagnose codes:

• V81.0 — Special screening for ischemic heart disease

• V81.1 — Special screening for hypertension or

• V81.2 — Special screening for other and unspecified cardiovascular conditions

 

 

Tips to correct the denied claim

This denial is usually correct, as utilization is checked against the common working file (CWF) for the patient.

If you have submitted the claim with a GA modifier and have an Advanced Beneficiary Notice (ABN) on file, you may hold the patient financially responsible.

However, if you submitted the claim erroneously without the GA or other modifier, submit your claim for a .

Denial Reason, Reason/Remark Code(s)

PR-119: Benefit maximum for this time period or occurrence has been met

 

 

Resolution/Resources

On January 1, 2006, Medicare implemented financial limitations on covered therapy services (therapy caps).  An exception to the therapy cap may be made when a beneficiary requires continued skilled therapy, (in other words, therapy beyond the amount payable under the therapy cap) to achieve his or her prior functional status or maximum expected functional status within a reasonable amount of time. Documentation supporting the medical necessity of those therapy services must be available in the patient’s medical record.

Verify whether the patient has exceeded the therapy cap prior to submitting claims to Medicare through the Palmetto GBA eServices tool or Interactive Voice Response (IVR) unit.

Online Verification for Therapy Caps through eServices

All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

Access the introductory article to learn more by selecting the ‘Introducing eServices’ graphic on the top of any of our contract home pages

Please Note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.

Billing services and clearinghouses should contact their provider clients to gain access to the system.

If the service qualifies as an exception and may be reimbursed over and above the cap, submit HCPCS modifier KX with the service. Documentation in the patient’s medical record must support the use of this modifier.

HCPCS modifier KX must be submitted in addition to HCPCS modifier GN, GO or GP with therapy services when therapy cap meets all guidelines for an automatic exception. HCPCS modifier KX allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.

 

 

Learn More…

Understanding the Need of Botulinum Toxin Therapy

More Freedom for Therapists in New 1135 Waiver

 

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