Receiving the PR96 denial

There are several instances in which a provider could receive this denial. The most obvious is when an item is simply not covered by Medicare, such as diapers, shower chairs, etc. A provider would bill Medicare for these items if there is a secondary payer that is requesting to see the non-covered denial from Medicare.

There are also some billing errors that lead to the PR96 denial. Surgical dressings require that a modifier be added to each HCPC to indicate the number of wounds present: A1, A2, A3, etc. In order to add this modifier, the patient must have one of the covered wound types listed in the medical policy. The exclusion of this modifier will result in a PR96 denial. If this modifier is left off mistakenly, the provider can take the claim through the reopenings process to add the modifier.

Another billing error involves the use of the KX modifier on urological claims. The KX modifier indicates that all documentation required by the medical policy is on file.

If this modifier is excluded in error, it will again result in a PR96 denial. The provider can also take this claim through the reopenings process to have the modifier added.

Since the use of denial codes is not uniform in all Medicare regions, there are occasions where the PR96 will appear as a result of overutilization. Traditionally, overutilization is denied by Medicare as a CO57. However, recently some regions have begun to use the PR96 in its place.

Since this denial is coded as patient responsibility, the balance can be transferred either to a secondary payer or the patient. Make sure that if the balance is transferred the denial was received, because Medicare considers the item non-covered for the patient and not because of a billing error.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. She can be contacted at 419/448-5332 or [email protected].

Based on analysis of 3,680,443 claims adjudicated by the Medicare contractors between July 1, 2006, and Sept. 30, 2006, and processed for RemitDATA customers. Source: RemitDATA, 866/885-2974, www.remitdata.com.