License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Reason Code Search and Resolution

Disclaimer: This is not a complete list of reason codes.

The Reason Code Search and Resolution tool allows you to view a reason code description and determine how to prevent/resolve the edit. You may search by reason code or keyword. All records matching your search criteria will be returned for your review. You may also select "Show all Reason Codes" to view the complete list.

If the reason code you enter does not display here, you may access any reason code description in the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) Reason Codes Inquiry Menu (Option 17) . For additional information, please reference the FISS DDE User Manual.

Search by:

Reason Code

Keyword

Reason Code 38107

Description:

Home health final claim submitted; however, a processed, matching RAP cannot be found.

Resolution:

Prior to submitting the final claim, access FISS Claim Inquiry option (Option 12) to determine if the RAP is in FISS status/location (S/LOC) P B9997
- You should not submit the final claim for the episode unless the RAP is in this S/LOC
Review your Medicare Remittance Advice timely to verify the RAP has completed processing
Submit the final claim timely according to regulations under the Home Health Prospective Payment System (HH PPS) and the Patient Driven Groupings Model (PDGM) based on the dates of service of the claim.
- Under HH PPS, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the episode
- Under PDGM for periods of care beginning January 1, 2020, submit the final claim prior to the greater of 60 days from when the RAP paid or the end of the 30-day period of care.
Prior to submitting the final claim, ensure the RAP has not auto-canceled
- Step 1: Access FISS Inquiry Option 12
- Step 2: Enter your HHA's National Provider Identifier in the NPI field
- Step 3: Enter the beneficiary's Medicare number in the MID field
- Step 4: Enter P B9997 in the S/LOC field
- Step 5: Enter 328 in the TOB field
- Step 6: Enter your episode's start date in the FROM date field
- Step 7: Press Enter
- FISS will return a listing of billing transactions that meet the criteria entered
- If a 328 type of bill is displayed, tab down to it and key an "S" in the SEL field
  - Press Enter
  - Press your F8 key to page forward to FISS Page 03
  - Review the information in the ADJUSTMENT REASON CODE field at the bottom of the screen
  - If the letters NF appear in this field, FISS auto-canceled your RAP because the final claim was not received timely
  - If your RAP auto-canceled, re-bill the RAP and wait for it to process (P B9997)
  - Submit the final claim for the episode
- If FISS does not return a 328 TOB, press your F3 button and follow Steps 1 through 7
  - If FISS still does not return a 328 TOB, then your RAP did not auto-cancel
  - Submit the final claim for the episode
Prior to submitting the final claim, ensure that the key information, listed below, for the episode's RAP and claim matches.
- Provider number/identifier of the billing home health agency (FL 56)
- "FROM" date of the episode (FL 6)
- Date of admission (FL 12)
- First four positions of the Health Insurance Prospective Payment System (HIPPS) code (FL 44)
  - If the fifth position of the HIPPS code needs to change based on the provision of non-routine supplies, your HHA should ensure that the supply severity level between the RAP and final claim for the same episode of care does not change.
- Date of service billed with the HIPPS code (FL 45)

Disclaimer: CGS' online tools and calculators are informational and educational tools only, designed to assist suppliers and providers in submitting claims correctly. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided. Although we've made every reasonable effort to provide effective resources, CGS is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information that these tools provide. CGS is not responsible for any human or mechanical errors or omissions.