March Clinical Appeals

Denial Reason Code W7020- NCCI Edit Update

In February, CMS rescinded the National Correct Coding Initiative (NCCI) Edits which restricted the billing of CPT codes 97530 and 97150 on the same day as billing of PT/OT evaluation codes (97161, 97162, 97163, 97164, 97165, 97166) retroactively to January 1, 2020. Nonetheless, many providers have experienced line item denials due to the edit enacted for the short duration. These line item denials are reflected by reason code W7020. To resolve, CMS will be correcting the NCCI edit, beginning April 6, 2020. Medicare Administrative Contractors (MACs) will automatically reprocess claims, without provider action.  When reconciling payments,

  • Review Part B line items for denial of HCPCs 97530 and 97150, in the presence of evaluation codes 97161, 97162, 97163, 97164, 97165, 97166.
  • If line item denials are identified, determine if reason code W7070 is appended.
  • If confirmed, flag impacted claims for review for automatic reprocessing following CMS correction of the edit, beginning April 6, 2020.
  • CMS has indicated provider action is not required.
  • Follow up with your MAC should reprocessing not occur or occur with errors.

SNF Claims Incorrectly Cancelled

From January 26 through February 16, 2020, a software issue caused SNF claims to be incorrectly cancelled with a message that there was no three-day qualifying hospital stay. This issue has been corrected. If your claims were incorrectly cancelled, re-bill them in sequential order to receive payment.

  • Claims need to process in date of service order for each stay for the Variable Per Diem (VPD) to calculate correctly.
  • Submit claims in sequence and wait at least 2 weeks before billing subsequent claims.
  • Some of the affected claims with older dates of service will require a timely filing exception; enter “Resubmission due to non-qualifying stay” in the remarks field.

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