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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 U538F

Description:

A Request for Anticipated Payment (RAP) or final claim overlaps an existing period of care with the same provider number and the "FROM" date equals the period of care start date OR a visit date on a final claim falls within another period of care established by another home health agency (HHA) or the billing HHA.

HHAs receive this error most often when they submit a second RAP for a period of care where the final claim for the same period of care was previously submitted and rejected (FISS status/location (S/LOC) R B9997). Example: An HHA submits a RAP and final claim for a period of care from 06/25/YY to 07/24/YY. The final claim rejects to S/LOC R B9997. The HHA submits a second RAP for 06/25/YY - 06/25/YY, which is sent to RTP (T B9997) with reason code U538F.

Billing errors for this reason code may also occur when a home health agency submits a final claim and it contains a visit date (line item date of service - LIDOS) that overlaps another HHA's period of care or the billing provider's subsequent period of care. Example: ABC Home Care submits a final claim for 04/21/YY - 05/20/YY, which contains a LIDOS for 05/08/YY; however, XYZ Home Care has already established an episode from 05/05/YY to 06/03/YY, which is posted to Common Working File (CWF) for the beneficiary. ABC Home Care's final claim is sent to RTP with reason code U538F because their 05/08/YY visit falls within XYZ Home Care's 05/05/YY - 06/03/YY period of care.

HHAs may also receive this error when they submit a final claim with dates of service that overlap two separate episodes established by the HHA. This occurs when HHAs submit multiple RAPs during the same 60 day episode, which creates multiple episodes for the beneficiary on CWF.

Resolution:

  • Submit only one RAP and final claim for each episode of care. If the final claim for the episode rejects, do not submit a second RAP. The final claim will need to be adjusted or resubmitted. See the Resolving Rejected Home Health Claims Caused by Billing Errors Web page for assistance in determining whether to adjust or resubmit a rejected home health final claim.
  • Prior to admission or submitting RAPs/claims to Medicare, check the beneficiary's eligibility file to review established home health episodes, which may impact your dates of service.
    • See the CGS Checking Beneficiary Eligibility web page for more information about the systems available to providers to check Medicare beneficiary eligibility information.
  • If another HHA's period of care overlaps your dates of service AND you are disputing their period of care, you must follow the instructions for resolving a transfer dispute prior to contacting CGS for assistance. Also review the information regarding beneficiary elected home health transfers.
  • If another HHA's period of care overlaps your dates of service AND there is NO dispute regarding the dates of service, remove the overlapping dates from your claim. Instructions for deleting revenue lines are accessible in Chapter Five - Claims CorrectionPDFof the Fiscal Intermediary Standard System (FISS) Guide.
  • The only time HHAs should submit a second RAP during a period of care that they have established is when the beneficiary is discharged due to meeting the goals of the plan of care and is readmitted to the agency during that same 30-day period of care. More information on this topic is available in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10,§ 10.1.5, 10.1.14 and 30.9External PDF). For assistance in correcting home health episodes posted to the CWF, see the Correcting Home Health Episode Information Posted to the Common Working File (CWF) Web page.

Additional Resources

Updated: 01.22.20


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