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Reason Code Search and Resolution

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

This Reason Code Search and Resolution tool has been designed to aid Medicare providers in reviewing reason codes and how to resolve the edit or use them for determining if other action is needed. You may search this database by reason code or keyword. All records matching your search criteria will be returned for your review. Or, if you wish, you may also view the entire listing of reason codes, their descriptions, resolutions, and additional billing information by clicking on the "Show all Reason Codes" option.

If no reason code displays, access the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) and select Option 17 “Reason Codes” from the Inquiry Menu to review the reason code description. For additional information refer to the Chapter 3: Inquiry MenuPDF of the FISS DDE Guide.

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Reason Code 38157

Description:

The Fiscal Intermediary Standard System (FISS) has found a previously submitted billing transaction for the same beneficiary and dates of service with the same provider number; therefore, the second billing transaction submitted by the provider is a duplicate.

Resolution:

  • When using batch file transfer software, have an internal procedure in place to ensure batches of billing transactions are deleted from the software once they are submitted to Medicare.
  • Review Medicare Remittance Advice timely.
  • Stay current in posting payments received from Medicare.
  • Access the FISS Claim Inquiry Option (Option 12) to determine which claims have been submitted to Medicare. For instructions on using FISS Inquiry Option 12, see Chapter 3 - Inquiry MenuPDFof the Fiscal Intermediary Standard System (FISS) Guide.
  • Do not resubmit an identical billing transaction if you have already corrected the claim from the Return to Provider (RTP) file.
    • We encourage you to suppress the view of claims in your RTP file that you do not intend to correct. See Chapter 5 - Claims CorrectionPDFof the Fiscal Intermediary Standard System (FISS) Guide for instructions on suppressing the view of claims in RTP.
  • When appropriate, adjust rejected (R B9997) or paid (P B9997) claims instead of resubmitting them.
  • If a billing transaction needs to be cancelled and resubmitted, the original billing transaction must be in FISS status/location P B9997 prior to the submission of the cancel claim. Prior to rebilling the corrected billing transaction, the 'cancel' claim (type of bill (TOB) XX8) must also be in P B9997.
    • See Chapter 5 - Claims CorrectionPDFof the Fiscal Intermediary Standard System (FISS) Guide for detailed instructions on adjusting or canceling home health and hospice billing transactions.
  • Ensure the TOB submitted is appropriate for the billing action needed, e.g., ensure that the TOB for an adjustment ends with a '7' and not '9', etc. For a listing of the appropriate types of bills submitted to Medicare, please review the appropriate chapter of the Medicare Claims Processing ManualExternal Website (CMS Pub. 100-04) for your provider type.

Providers should be aware that duplicate billing errors impact the Medicare program negatively by increasing the cost to process Medicare claims. Providers are also negatively impacted by the consequences of duplicate billing such as:

  • Payment delays,
  • Identification as an abusive biller, or
  • The initiation of a fraud investigation if a pattern of duplicate billing is identified.

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