Routine Physical Exams: Statutory Denials

Denial Reason, Reason/Remark Code(s)

With a valid ABN:

  • PR-204: This service/equipment/drug is not covered under the patient's current benefit plan
  • PR-N130: consult plan benefit documents/guidelines for information about restrictions for this service.

Without a valid ABN:

  • CO-204: this service/equipment/drug is not covered under the patient's current benefit plan
  • CO-N130: Consult plan benefit documents/guidelines for information about restrictions for this service.

CPT code: 99397 (Status "N" on MPFSDB)

Resolution/Resources
  • Routine physical exams are never covered by Medicare except under the 'welcome to Medicare physical' or 'initial preventive physical exam' (IPPE) guidelines. For more information on the IPPE, refer to the CMS website for preventive services:
  • The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient's right to a determination.
  • If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
Notice of Exclusion from Medicare Benefits Information
If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets you know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
  • CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the 'old' Notice of Exclusion from Medicare Benefits (NEMB) language. Use of the revised ABN is optional for services that are excluded from Medicare benefits. Access the revised ABN and other background information from the CMS website.
  • If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup tool (located under Self Service Tools on the Palmetto GBA Web page) for information on HCPCS modifier GY or GA.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now