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Reason Code Descriptions and Resolutions

Reason Code 10420

Description:

This outpatient claim contains services on a SNF claim. The services should be included on the SNF claim.

Resolution:

If appropriate, make corrections and submit a new claim to the Medicare Administrative Contractor.

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Reason Code 12206

Description:

The sum of covered days and non-covered days must equal the statement covers period. When the from and through dates are not the same on an inpatient or SNF bill types, the number of days represented must equal the sum of the covered days plus the non-covered days, unless the patient status is 30. If the patient status is 30, one additional day is used in the calculation.

Resolution:

Verify billing, and if appropriate correct the claim or resubmit.

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Reason Code 19301

Description:

A principal procedure code or a surgical CPT/HCPCS code is present, but the operating physician's National Provider Identifier (NPI), last name, and/or first initial is missing.

Resolution:

Report the operating physician's NPI, last name, and first initial in the operating physician fields and F9/ resubmit the claim.

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Reason Code 30905

Description:

The adjustment claim submitted cannot be matched to a claim previously processed. Therefore, no adjustment can be performed.

Resolution:

Verify that the claim you want adjusted is in a finalized status (PB9997) prior to submitting an adjustment. Verify that the provider number, HIC number, from date and DCN on the adjustment claim match those same data elements on the remittance advice containing the original payment.

Verify billing and if appropriate, correct. F9 and resubmit the claim.

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Reason Code 30906

Description:

The incoming adjustment cannot find an original claim to match. Verify that the following fields on the adjustment are identical to those same fields on the remittance advice containing the original payment:

  • HIC NUMBER
  • X-REFERENCE DCN
  • FIRST TWO POSITIONS OF THE TYPE OF BILL
  • DATES OF SERVICE
  • PROVIDER NUMBER

Resolution:

Verify billing and if appropriate, correct. Online providers should F9 to store the claim. If these are electronically submitted adjustments, verify with your vendor that the document control number (DCN) of the claim you are adjusting is in the appropriate loop and segment. Resubmit the adjustment ensuring that the DCN is in the correct loop and segment.

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Reason Code 30912

Description:

This adjustment is adjusting an adjustment that has previously been adjusted.

Resolution:

Check claim summary for previously adjusted claim. Make corrections and resubmit.

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Reason Code 30940

Description:

A provider is not permitted to adjust a partially or fully medically denied claim.

Resolution:

Appeal the claim. If applicable a provider initiated reopening TOB (XXQ) may be submitted.

Reference: SE1426 – Scenarios and Coding Instructions for Submitting Requests to Reopen Claims that are Beyond the Claim Filing Timeframes – Companion Information to MM8581: "Automation of the Request for Reopening Claims Process"External PDF

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Reason Code 30949

Description:

An adjusted claim contains frequency code equal to a ‘7’, ‘Q’, or ‘8’, and there is no claim change reason code (condition code D0, D1, D2, D3, D4, D5, D6, D7, D8, D9, or E0.

Resolution:

Add the applicable claim frequency code (condition code) and F9, or you may submit as a new claim.

Note: If, after reviewing the error(s), you decide that you would rather resubmit the billing transaction than to correct it, you may do so. Duplicate claim editing does not apply to claims in the RTP file. CGS encourages you to suppress the view of any billing transaction that you do not intend to correct. Instructions for suppressing the view of claims are found in the DDE Claims Correction Manual, Chapter 5PDF - page 10.

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Reason Code 30955

Description:

The adjustment (XX7) or Cancel (XX8) bill contains an invalid cross reference DCN. The cross reference DCN should be the Document Control Number of the original processed claim that is either being adjusted or canceled.

Resolution:

Verify that the correct Direct Data Entry (DDE) screen is being used for the adjustment (attempting to adjust a claim on the correction menu). If adjustment was attempted on the correction screen, disregard and verify that you are on the correct menu to cancel a claim. Do not attempt to suppress the incorrect adjustment from the correction screen. Make appropriate corrections and F9 claim or resubmit.

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Reason Code 31102

Description:

Your claim is being returned due to one of the following:

  1. Value code dollar amount equal greater than 0.00.
  2. Occurrence code 24 and date insurance denied not present.
  3. Any required condition codes or occurrence codes not present based on MSP value code.
  4. Two digit MSP explanation codes and date if required not present.
  5. If billing value codes 15 or 47 and the benefits are exhausted please contact the BCRC to update the records and bill primary.
  6. Value Codes 16, 41, and 42 should not be billed conditional. You should bill Medicare primary.
  7. Value code 13 and value code 12 or 43 cannot be billed on the same claim.
  8. Insurance name and address do not match what is on MSP Record at CWF. Contact the BCRC to update the records.
  9. Patient relationship code being billed doesn't match MSP record on CWF. Contact the BCRC and have records updated.

Please make corrections and resubmit your claim.

Resolution:

For assistance on how and when to bill Medicare secondary, refer to the following article on the CGS website.

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Reason Code 31689

Description:

Medicare is secondary or tertiary and the dollar amount entered in the PD AMT field on MAP1719 (F11 on page 3) is not equal to the dollar amount entered for the MSP Value Code (12, 13, 14, 15, 41, 43, or 47).

Refer to MM8486: Instructions on Utilizing 837 Institutional Claim Adjustment Segment (CAS) for Medicare Secondary Payer (MSP) Part A Claims in Direct Data Entry (DDE) and 837I 5010 Claims TransactionsExternal PDF

Resolution:

Check claim and correct amount entered on MAP1719 or the dollar amount entered for the MSP Value Code. F9 or resubmit claim.

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Reason Code 31860

Description:

The claim entered has a type of bill equal to 21X or 18X, occurrence code 22 on the claim matches the statement covers through date, but the patient status is not equal to 30 (still a patient).

Resolution:

Verify the patient status billed on the claim. Correct, and F9 or resubmit a corrected claim.

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Reason Code 32114

Description:

Effective 04/01/2015:

For outpatient types of bills 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X AND 85X, a valid 9 digit ZIP Code must be submitted in the service facility ZIP Code field,

A valid 9 digit ZIP Code is defined as:

  • The first 5 digits must be a valid ZIP Code located on the CMS ZIP Code file
  • The plus 4 ZIP Code must be present and not equal to 0000 or 9999

Resolution:

Obtain the valid 9 digit ZIP Code and enter it on RTP'd claim in DDE and F9, or submit as a new claim.

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Reason Code 32206

Description:

The revenue code is not valid for this type of bill, or the covered charges are not valid for this type of bill, or services not covered by Medicare.

Resolution:

Verify revenue code billed on line editing. Correct, and F9 claim.

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Reason Code 32400

Description:

A HCPCS code is required for a revenue code reported on this claim. However, a HCPCS code is missing.

Resolution:

Verify the revenue code(s) billed. Verify a HCPCS code is reported for every revenue code that requires one.

Make corrections and F9 or resubmit the claim with the required HCPCS.

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Reason Code 32242

Description:

A non-covered revenue code is shown on the claim with  covered charges greater than $0.00.

Resolution:

Determine if the correct revenue code is being used. If the revenue code is correct, move the covered charge amount for that line to the non-covered charge field. If incorrect, change the revenue code.

Online users make corrections and F9, or submit a new claim.

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Reason Code 32352

Description:

Invalid type of bill for this HCPCS based on the 'HCPC TOB TABLE'. Please verify billing.

Resolution:

If billing is incorrect, correct, and F9 or resubmit the claim.

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Reason Code 32400

Description:

A HCPCS code is required for a revenue code reported on this claim. However, a HCPCS code is missing.

Resolution:

Verify the revenue code(s) billed. Verify a HCPCS code is reported for every revenue code that requires one.

Make corrections and F9 or resubmit the claim with the required HCPCS.

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Reason Code 32402

Description:

Revenue/HCPCS code combination error - The revenue code reported is not billable with this HCPCS code.

Resolution:

Review the revenue and HCPCS codes for keying errors, correct, and F9/resubmit the claim.

Some items and services can only be billed with certain revenue codes. If you have access to the Direct Data Entry (DDE) system, you may view the revenue codes that are billable with a particular HCPCS code in the HCPCS inquiry screen:

  • Select option 01 (Inquiries).
  • Select option 14 (HCPC Codes).
  • Key the HCPCS code in the HCPC field and press Enter.
  • The appropriate revenue codes are listed under the Allowable Revenue Codes field. If no revenue codes are listed, the HCPCS code can be billed with any revenue code.

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Reason Code 32404

Description:

The revenue code file indicates that a HCPCS code is required. Either the HCPCS code is missing from the claim or is not on file for one of the following reasons:

  1. The HCPC code entered on the claim is not a valid HCPCS/CPT code.
  2. The HCPCS code entered on the claim is not billable to Medicare. For example: Codes beginning with 'S' or 'T'.

Resolution:

There is an issue with this reason code that is mentioned on the Part A Claims Processing Issue Log (CPIL). If you feel your claim is RTPing in error, F9 and your claim will be suspended until the correction goes in.

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Reason Code 32415

Description:

Condition code 'A6' is required when billing the influenza or pneumococcal vaccine(s) and/or administration.

Resolution:

Append the 'A6' condition code to the claim and F9, or resubmit.

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Reason Code 34538

Description:

Claim submitted as Medicare primary and a positive working elderly record exists at the Common Working File (CWF).

Resolution:

The claim should be billed to the Employer Group Health Plan (EGHP). Reformat claim and submit an adjustment.

Note: If you have information that disputes the CWF, use the information in the following link to verify how to resolve:  https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Overview.htmlExternal Website

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Reason Code 34932

Description:

Acute care hospital claims must contain a valid present on admission (POA) indicator. Valid values and other information is described in the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding.htmlExternal Website

Resolution:

Verify billing. If appropriate, correct. Online providers should F9 to store the claim.

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Reason Code 34961

Description:

Present on Admission (POA) Indicator or End of POA Indicator is present on an Outpatient claim (TOB other than 11X, 18X, or 21X).

Resolution:

Remove POA Indicator and F9 or resubmit claim.

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Reason Code 34977

Description:

The claim was returned due to one of the following:

  • The service facility address submitted on the claim was not identified by the provider as a practice location address when the CMS-855A enrollment form was submitted.
  • The service facility address submitted on the claim is not an exact match to the practice location address in PECOS.

Resolution:

  • To add a new or correct an existing practice location address, submit the CMS-855A enrollment form in PECOS.
  • Or, verify the address format in PECOS, DDE, or myCGS portal, ensure the service facility address on the claim is an exact match, and resubmit the claim.

Reference:

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Reason Code 34978

Description:

One or more line items on the claim do not contain a PO, PN, or ER modifier.

Resolution:

  • Report the PO modifier for any services provided at an excepted off-campus provider-based department.
  • Report the PN modifier for any services provided at a non-excepted off-campus provider-based department.
  • Report the ER modifier for any services provided at an off-campus provider-based emergency department.

Reference:

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Reason Code 37541

Description:

Provider submitted adjustment (XX7 or XXQ) is for 'Other' reasons not identifiable with specific claim change reason (condition code) which equals 'D9'.

Resolution:

If using change reason code 'D9', add 'REMARKS' to indicate why the adjustment being performed, and not using a claim specific reason code (condition code).

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Reason Code 37544

Description:

Provider submitted adjustment (XX7 or XXQ) indicates adjustment is due to changes in charges. Condition D1 is present and all charges on the adjustment bill equal the charges on the original claim. If D1 is present, covered charges must differ.

Resolution:

Verify information is keyed correctly. Correct keying errors and F9 or resubmit the claim.

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Reason Code 38032

Description:

The outpatient claim is a duplicate of a previously processed outpatient claim. The following conditions exist on both claims: 

  1. Statement from and through dates are the same 
  2. Provider numbers are the same
  3. At least one revenue code matches

Resolution:

Adjust rejected claim and enter correct information. Submit adjustment.

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Reason Code 38038

Description:

A history claim is present that contains overlapping dates, with the provider numbers equal, and at least one line item date of service is equal (for OPPS services) without condition code 'GO', '20', or '21' present on the claim.

Resolution:

If ancillary services are being billed, a Part A inpatient claim (benefits exhaust or no entitlement), a 121 type of bill for ancillary services may be billed, and a 131 type of bill for ER visit only.

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Reason Code 38117

Description:

All inpatient SNF and Non-PPS bills must be processed in sequence. There is a prior claim for this admission pending in the system.

Resolution:

Verify the admission date and from date on the claim. If admission and from dates are correctly reported, hold the claim until the pending bill has shown on your remittance advice. Once the prior claim has shown on the remittance advice, the next claim can be submitted.

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Reason Code 38119

Description:

Inpatient Skilled Nursing Facility (SNF) and non-Prospective Payment System (PPS) hospital bills must be processed in the same sequence in which the services were furnished. The claim immediately preceding the dates of service on this claim has not yet processed.

Resolution:

  • Verify the information submitted on the claim.
  • If errors are identified, correct and F9/ resubmit the claim.
  • If the information submitted on the claim is correct, submit the prior month's bill.
  • After the prior month's bill processes, F9/ resubmit the subsequent claim.

References:

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Reason Code 38200

Description:

This claim is an exact duplicate of a previously submitted claim.

Resolution:

  • Verify the information submitted on the claim.
  • If you need to correct information on the previously submitted claim, submit an adjustment claim.

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Reason Code 39011

Description:

The claim was not submitted timely. Medicare regulations require claims to be submitted within one year of the date of service (through ‘To’ date of service on the claim).

Resolution:

If claim is not timely, a Reopening Adjustment (XXQ) type of bill may be applicable.

Reference: Refer to Timely Filing Guidelines and Automated ReopeningsPDF.

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Reason Code 39132

Description:

This is an outpatient claim (Type of Bill 12X, 13X, or 14X) in which the Outpatient Prospective Payment System (OPPS) reimbursement is greater than the covered charges reported on the claim.

Resolution:

  • Access the claim. The Remarks section will include the code(s) in question.
  • Verify the code(s), unit(s), and charges are reported correctly.
  • If correct, indicate the following in Remarks and F9/resubmit the claim: Code or codes have been verified.
  • If any of the line item information was reported incorrectly, correct the information and F9/resubmit the claim.

Reference:  MLN Article 7771External PDF Prior to the initial submission of the claim, if providers are aware that the claim has a comprehensive APC that could be causing the reason code, they may indicate in Remarks that the charges have been verified. This will prevent the claim from RTPing with reason code 39132.

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Reason Code 39910

Description:

Review all of external narrative to see if one of the situations applies (#1 - #4). #5: Claim type of bill 71X (Rural Health Clinic (RHC), refer to MM9269 and SE1611 for billing requirement.

Resolution:

Verify billing and if appropriate, correct.

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Reason Code 39929

Description:

All line items on the claim are rejected or rejected/denied.

Resolution:

  • Line item rejection/denial information can be obtained from the remittance advice or via the Direct Data Entry (DDE) system. Review the reason for rejection/denial and verify the information submitted on the claim.
  • If an error on the claim caused the line item rejection, you may submit an adjustment claim to correct the error.
  • Line item denials are usually medical necessity denials. If you disagree, you may request a redetermination (first level of appeal).

References:

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Reason Code 39934

Description:

All line items on the claim are denied as non-covered and one or more lines denote beneficiary liability.

Resolution:

  • Line item denial information can be obtained from the remittance advice or via the Direct Data Entry (DDE) system. Review the reason for denial and verify the information submitted on the claim.
  • Line item denials are usually medical necessity denials. If you disagree, you may request a redetermination (first level of appeal).

References:

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Reason Code C7252

Description:

For an oupatient claim, the detail line item date of service is within the admission and discharge date of a SNF inpatient Part A Claim (21X) for non-therapy services.

Resolution:

Make correction(s),and  F9 or resubmit claim.

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Reason Code U5061

Description:

The Health Insurance Claim (HIC) number is not found in the Common Working File (CWF) Crosswalk.

Resolution:

Verify eligibility to see if the Medicare number is valid. This could be a potential claim issue. Monitor the J15 Part A Claims Processing Issues Log  on the J15 Part A Website for more information.

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Reason Code U5200

Description:

The CMS records indicate that the beneficiary is not entitled to Medicare coverage for this type of services billed on the claim. Therefore, no Medicare payment can be made.

Resolution:

Check/Verify Entitlement by Calling the Interactive Voice Response (IVR) at 866.289.6501 (Option 1), using HETS, or Direct Data Entry (DDE), using the ELGA/HIQA Option.

For more information about HETS and how to obtain access to the system, refer to the CMS HETS Help web pageExternal website on the CMS website.

For Information on obtaining eligibility in DDE, refer to the Checking Beneficiary EligibilityExternal PDFChapter of the DDE User Manual/FISS Reference Guide.

Note: The DDE Option will be discontinued in the future.

Resubmit claim with correct eligibility information.

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Reason Code U5233

Description:

The services on the claim fall within or overlap a Medicare Advantage (MA) managed care plan enrollment period.

Resolution:

  • Obtain the managed care plan information from the Direct Data Entry (DDE) system, the Interactive Voice Response (IVR), or the myCGS web portal. Submit a claim to the managed care plan for payment.
  • For certain inpatient services, an informational-only claim must be submitted to Medicare for the purpose of tracking benefit utilization and, in some cases, for the provider to receive special payments. Informational-only claims are submitted as follows:

      Acute IRF LTCH CAH SNF/SB
    Non-teaching facility Covered claim with condition code 04 for Disproportionate Share Hospital (DSH) payment Covered claim with condition code 04 and the Case-Mix Group (CMG) code and assessment date from the IRF Patient Assessment Instrument (PAI) for Low-Income Patient (LIP) payment Covered claim with condition code 04 for DSH payment Covered claim with condition code 04 for Electronic Health Record (EHR) incentive payment Submit claim to the managed care plan for payment; submit the same claim to Medicare to track benefit utilization
    Teaching facility Covered claim with condition codes 04 and 69 for DSH and Direct Graduate Medical Education (DGME) payments Non-covered claim with condition codes 04 and 69 for LIP and DGME payments Non-covered claim with condition codes 04 and 69 for DSH and DGME payments Not applicable Not applicable

    Note: Managed care informational-only claims are not required for outpatient hospital or Inpatient Psychiatric Facility (IPF) services. If requesting a denial based on coverage by a managed care plan, submit the claim as covered without condition code 04 or 69.

  • If the beneficiary is enrolled in a managed care plan for only a portion of an inpatient stay, submit the claim as follows:

    IPPS IPF IRF LTCH CAH Non-IPPS SNF/SB
    • If Medicare is primary upon admission, bill the entire claim to Medicare.
    • If the managed care plan is primary upon admission, bill the entire claim to the managed care plan.
    • Bill the managed care plan for days the patient is enrolled in the managed care plan.
    • Bill Medicare for the days the patient is not enrolled in the managed care plan.

    Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1External PDF, section 90

  • If the beneficiary is enrolled in a managed care plan and elects the hospice benefit, all hospice and non-hospice related services beginning on the date of the hospice election are billed to Medicare as follows:
    • Hospice services covered under the Medicare hospice benefit are billed by the hospice provider to the Home Health and Hospice (HH&H) Medicare Administrative Contractor (MAC).
    • Services provided by the enrollee's attending physician (if the physician is not employed by or under contract to the enrollee's hospice) are billed by the physician to Part B of the A/B MAC.
    • Services not related to the treatment of the terminal condition are billed by the provider to Part A of the A/B MAC with condition code 07.
    • Services furnished after the revocation or expiration of the enrollee's hospice election are billed accordingly until the full monthly capitation payments begin again. Monthly capitation payments begin on the first day of the month after the beneficiary revokes the hospice election.

Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 11External PDF, section 30.4

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Reason Code U6819

Description:

The diagnosis on the incoming claim matches or is within the family of diagnosis codes to a diagnosis posted for a non-GHP MSP occurrence.

Resolution:

Verify MSP record in the Common Working File (CWF) and resubmit claim accordingly.

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Reason Code W7006

Description:

An invalid HCPCS procedure code has been billed.

Resolution:

Verify billing, and correct if appropriate. F9 or resubmit the claim.

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Reason Code W7062

Description:

The HCPCS code used on the claim was not recognized by OPPS.

Resolution:

Alternate Code for same service may be available. Verify and resubmit claim with corrected code.

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Reason Code W7088

Description:

FQHC PPS TOB 77X is submitted and at least one of the specific payment codes (G0466, G0467, G0468, G0469, or G0470) is not present.

Resolution:

Verify billing instructions in CR8743 and add appropriate HCPCS code(s). F9 claim or resubmit.

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Reason Code W7099

Description:

Claim with pass-through or non-pass-through drug or biological lacks OPPS
payable procedure.

Resolution:

Claims receiving this reason code in error are being suspended until the January 2017 Integrated Outpatient Code Editor (IOCE) is implemented.

If there are claims that are RTP'd in error, F9 and resubmit, and claims will be suspended until the correction is implemented.

NOTE: There was an additional issue with W7099 editing incorrectly on non-OPPS claims. CMS and FISS have provided a work around for this issue. If you have claims RTP'd in error, F9 those claims for the work around to be applied.

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