Remark code N115 indicates that the payment decision for the claim was made in accordance with a Local Coverage Determination (LCD). LCDs are policies issued by Medicare Administrative Contractors that define the conditions under which a service or item is considered medically necessary and, therefore, eligible for coverage. Providers can access the specific LCD referenced by visiting www.cms.gov/mcd, or if they lack internet access, they can directly contact the contractor to obtain a copy of the policy.
Common causes of code N115 are:
1. The service or item billed is not considered medically necessary according to the LCD guidelines for the specific region or contractor.
2. The diagnosis code submitted does not match the conditions or indications listed in the LCD for the service or item provided.
3. The documentation submitted does not support the necessity of the service or item according to the LCD requirements.
4. The provider did not obtain the required prior authorization as stipulated by the LCD for the particular service or item.
5. The service or item is deemed experimental or investigational for the condition treated, as per the LCD.
6. The procedure or service was provided outside of the dates of service specified by the LCD.
7. The claim lacks the specific modifiers or does not meet the coding requirements outlined in the LCD for the billed service or item.
Ways to mitigate code N115 include ensuring that the services provided are in line with the most current Local Coverage Determination (LCD) guidelines. It is essential to regularly review the LCDs relevant to your specialty and the services you offer. Staff should be trained to understand and apply these guidelines when coding and billing for services. Additionally, implementing a robust pre-claim review process can help identify potential discrepancies with LCD requirements before claims are submitted. Utilizing advanced coding software that includes LCD compliance checks can also assist in preventing this code by flagging services that may not meet the necessary criteria. Regular audits of claim denials related to N115 can provide insights into common issues and help refine internal processes to avoid future occurrences.
The steps to address code N115 involve reviewing the Local Coverage Determination (LCD) relevant to the denied service or item. First, verify that the service or item provided matches the criteria outlined in the LCD. If the service or item is indeed covered, ensure that the documentation submitted with the claim supports medical necessity as defined by the LCD. If the documentation is lacking or does not align with the LCD requirements, update and resubmit the claim with the necessary supporting information. In cases where the service or item does not meet the LCD criteria, consider if an Advance Beneficiary Notice (ABN) was obtained, indicating the patient's acknowledgment of potential non-coverage. If an ABN was obtained, bill the patient accordingly. If the denial still seems incorrect after reviewing the LCD and supporting documents, prepare and submit a written appeal, including a detailed explanation and any additional supporting evidence to contest the decision.