Line level reason code to indicate that none of the diagnoses on the claim support the medical necessity of the service, and no documentation to support medical necessity was provided.

Service does not meet coverage requirements for a National Coverage Determination (NCD) and the provider is held liable if services are not billed correctly. The lines on the claim that lack a covered diagnosis will deny. Providers should review relevant NCDs and determine what diagnoses support medical necessity of the service. Also, examine the rules for issuance of an Advance Beneficiary Notice (ABN) and issue an ABN, when appropriate.

Resource: Outpatient Code Editor (OCE).


Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department

Click to Chat Now