Denial Reason, Reason/Remark Code(s)
• M86: Service denied because payment already made for same/similar service(s) within set time frame
• B14 (CO): Only one visit or consultation per physician per day is covered
• CPT Codes: 99213, 99214, 99231, 99232, 99233 and 99291
Resolution/Resources
First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA Online Provider Services (OPS) tool or by calling the Palmetto GBA Interactive Voice Response unit (IVR).
Online Claim Status Verification through OPS
• 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: Click on the 'Introducing Online Provider Services' graphic on the top of any of our main contract Web pages
• One important consideration: 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
• Specific instructions for accessing claim status information through OPS are available in the OPS User Manual.
Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. When more than one E/M service is provided to the same patient on the same date by more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Physicians in the same group practice but who are in different specialties or subspecialties may bill and be paid without regard to their membership in the same group.
• On electronic claims the documentation record could be used to specify the subspecialty of the provider when more than one service has been billed by multiple providers in the same group
• On electronic claims the documentation record could be used to explain why treatment was needed by a different provider in the same group
• Attachments (e.g., signed office notes, signed progress notes, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., subspecialty of the billing provider):
o Attachments must be a full page (8 ½ x 11)
• On appeal, signed medical records (e.g., progress notes, history and physical notes, office notes, etc.) may be sent as evidence to show why more than one visit was submitted on the same date either by similar providers from different groups or different providers with different subspecialties from the same group
• On appeal, the identification of the providers’ subspecialty, when more than one provider from the same group is billing for E/M services to the same patient on the same date, can be helpful in explaining why multiple providers were needed
We strongly encourage all providers and their staff members to become familiar with the E/M Documentation Guidelines, which were developed jointly by CMS and the American Medical Association.
• Take advantage of free training offered by Palmetto GBA clinical education staff to learn more about how to understand and apply the E/M Documentation Guidelines. To view a list of upcoming workshops, select Learning and Education from the left side of the Web page and then select Workshops.
• Conduct internal audits of documentation versus code selections, especially for E/M services
• Consider using a standardized 'scoring tool' for consistency in applying the E/M Documentation Guidelines. Palmetto GBA publishes one such tool on our website, although there are many others from which to choose.
• Review the E/M Documentation Guidelines on the CMS website
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