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

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

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

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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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 30919

Description:

This claim is processing against a claim already posted to CWF (Duplicate).

Resolution:

Verify the billing of claim to determine if claim posted to CWF is correct. If changes need to be made, adjust posted claim (TOB ending in 7) or submit a cancellation claim (TOB ending in 8) and then resubmit new claim after cancellation claim processes.

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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 31639

Description:

TYPE OF BILL IS 12X, 13X, 14X, 22X, 23X, 41X, 43X, 71X, 72X, 73X, 74X, 75X, 76X, 77X, 81X, 82X, 83X OR 85X AND COVERED AND NON-COVERED CHARGES ARE PRESENT ON THE SAME LINE.

Resolution:

Please verify covered and non-covered charges are entered correctly on the claim. If appropriate, make corrections and resubmit the claim.

Reference: Medicare Claims Processing Manual, Chapter 1, Section 60External PDF

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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 34300

Description:

Claim submitted with Medicare as the primary payer and a Worker's Compensation records exists in the Common Working File (CWF). Service is within the 120- day promptly period.

Resolution:

If the beneficiary has Worker's Compensation coverage that is primary, submit a claim to the primary payer before billing Medicare as secondary. If the Worker's Compensation record in CWF is incorrect, submit a conditional claim to Medicare to have the record updated.

Reference: Medicare Secondary Payer Manual, Chapter 5, Section 40.6External PDF

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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 34545

Description:

Claim submitted with Medicare as the primary payer and a Worker's Compensation records exists in the Common Working File (CWF). Service is within the 120- day promptly period.

Resolution:

If the beneficiary has Worker's Compensation coverage that is primary, submit a claim to the primary payer before billing Medicare as secondary. If the Worker's Compensation record in CWF is incorrect, submit a conditional claim to Medicare to have the record updated.

Reference: Medicare Secondary Payer Manual, Chapter 5, Section 40.6External PDF

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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 37098

Description:

The Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) supplemental rate is not present for the Medicare Advantage (MA) plan..

Resolution:

FQHC’s with a written contract with a MA organization are paid by the MA plan at the rate stated in their contract. Medicare pays the difference if the MA contract rate is less than the Medicare PPS rate. This is called a supplemental wrap around payment. Medicare does not make a supplemental wraparound payment if the MA contract rate is higher than the PPS rate.

The FQHC is responsible for ensuring their Medicare Administrative Contractor (MAC) has the current MA plan contract information. Claims will be returned with reason code 37098 when the FQHC PPS supplemental rate information is not updated for the MA plan. To have the MA plan information updated, FQHC’s must submit documentation showing an estimate of the average visit payment for the MA  enrollees. A cover letter should be included containing the provider list, contact name and contact signature. This information is required for each MA plan the FQHC has a contract with.

For each MA contract include:

  • Contract Number
  • Provider name
  • MA contract name
  • Contract Dates
  • Effective dates
  • Signature from provider
  • Signature from the MA contract representative

Rate calculation information should include:

  • Contract number
  • Procedure codes
  • Units
  • Rates
  • Payment amounts
  • MA payment rate per visit
  • A detailed list of claims that support the rate calculation

The information can be sent:

Reference: Medicare Claims Processing Manual, Chapter 9, Section 60.4

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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 37578

Description:

The service line contains a line level rendering physician NPI but the first digit of the NPI is not equal to 1 or the 10th digit of the NPI does not follow the check digit validation routine.

Resolution:

Review claim. Verify NPI of rendering physician. Correct and resubmit.

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Reason Code 38031

Description:

This outpatient claim is a possible duplicate to another outpatient claim

Resolution:

Verify the billing of claim. If there is another outpatient claim for the same date(s) of service, please combine on one claim. If changes need to be made to posted claim, adjust posted claim (TOB ending in 7) or submit a cancellation claim (TOB ending in 8) and then resubmit new claim after cancellation claim processes.

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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 C5468

Description:

A service on the claim requires prior authorization and no Unique Tracking Number (UTN) is present.

Resolution:

Part A hospital outpatient departments (OPD) must receive prior authorization for certain services performed in that setting. Hospital OPDs must submit a prior authorization request and receive a decision before rendering the service and submitting a claim. The UTN included in the prior authorization decision letter must be reported on the hospital OPD (TOB 13X) claim.

Reference:

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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 U5211

Description:

The services billed on the claim were provided after the beneficiary’s date of death.

Resolution:

  • Verify the beneficiary’s Medicare number and dates of service. If any corrections are needed, adjust/resubmit the claim.
  • If the date of death was reported in error to Social Security, they must be contacted to correct the date. If the beneficiary is actually alive, they must contact Social Security. This information cannot be corrected by CGS.

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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 U5373

Description:

CMS records show the beneficiary had a screening mammography paid in the last 11 months.

Resolution:

For women 40 years and over, Medicare pays annually for a screening mammography. To determine the beneficiary's next eligible date for a mammography, start your count beginning with the month after the month of the last screening mammography.

To determine if a beneficiary has received a screening mammography and their next eligible date for this service, check the Preventive sub-tab in the myCGS Web Portal: myCGS User Manual - Eligibility.

Reference: MLN006559 – Medicare Preventive ServicesExternal PDF

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Reason Code U5378

Description:

Medicare will not pay for certain colorectal cancer screening services when the beneficiary is under age 45.

Resolution:

Review the information about Medicare colorectal cancer screening coverage to determine the services covered for beneficiaries under age 45: MLN006559 – Medicare Preventive ServicesExternal PDF

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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 V8022

Description:

The outpatient physical therapy expense limit is overapplied. The physical therapy expense submitted is greater than the expense to be met.

Resolution:

Make sure therapy charges are reported correctly on the claim. Make any necessary corrections and resubmit the claim.

If appropriate, submit the KX modifier with the therapy services over the cap. This modifier is submitted to attest that the therapy services are reasonable and medically necessary and that there is documentation in the patient’s medical record to substantiate the medical necessity of the services.

References:

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Reason Code W1462

Description:

MCE has determined that the 6th procedure is a non-covered procedure, or if the procedure code is ‘375 (Heart Transplant) the certification date for the heart transplant on the provider file is missing.

Resolution:

Verify the 6th procedure billed. If appropriate, correct the claim or resubmit. A list of non-covered procedures can be located in the Definition of Medicare Code Edits file MS-DRG Classifications and Software | CMSExternal website.

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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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Reason Code W7123

Description:

The reported claim is submitted with a HCPCS and appended with a modifier designated as not reportable after the CMS termination date for the modifier.

Resolution:

Verify that the modifier is effective for the dates of service billed. If appropriate, correct the claim or resubmit.

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