Remittance Advice (RA) Messages M27, CO 50 AND M38

Use appropriate RA messages when processing claims.

For denials effective January 1, 2007, use the following RA messages:

Claim adjustment reason code 50:

"These are non-covered services because this is not deemed a "medical necessity" by the payer".

Include the following RA messages if an ABN was issued:

• RA remark code M38:

“The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay.”

• Group code PR:

“Patient Responsibility.”

If an ABN was not issued include the following messages:

• RA remark code M27:

“The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. You, the provider, are ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered.

You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office.”

• Group code CO:

“Contractual Obligations.”

Denial code - CARC 96, RARC N435 AND MSN 23.17

Effective for dates of service on or after June 11, 2013, contractors shall use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the KX modifier is not included, identified by Procedure codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier PS, HCPCS A9552, and the same cancer diagnosis code.

• CARC 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

• RARC N435: “Exceeds number/frequency approved/allowed within time period without support documentation.”


• MSN 23.17: “Medicare won’t cover these services because they are not considered medically necessary.”

Spanish Version: “Medicare no cubrirá estos servicios porque no son considerados necesarios por razones médicas.”
Contractors shall use Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.

Contractors shall use Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.

Rejection code CARC 4, MA 130, RARC M16 AND CARC 50

 Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes
Effective for dates of service on or after April 3, 2009, contractors shall return as unprocessable/return to provider claims that do not include the PI modifier with one of the PET/PET/CT Procedure  codes listed in subsection C. above when billing for the initial treatment strategy for solid tumors in accordance with Pub.100-03, NCD Manual, section 220.6.17.


In addition, contractors shall return as unprocessable/return to provider claims that do not include the PS modifier with one of the Procedure codes listed in subsection C. above when billing for the subsequent treatment strategy for solid tumors in accordance with Pub.100-03, NCD Manual, section 220.6.17.

The following messages apply:

• Claim Adjustment Reason Code (CARC) 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.

• Remittance Advice Remark Code (RARC) MA-130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.

• RARC M16 - Alert: See our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.

Effective for claims with dates of service on or after April 3, 2009, through June 10, 2013, contractors shall return as unprocessable/return to provider FDG PET claims billed to inform initial treatment strategy or subsequent treatment strategy when performed under CED without one of the PET/PET/CT Procedure  codes listed in subsection C. above AND modifier PI OR modifier PS AND a cancer diagnosis code AND modifier Q0/Q1.

The following messages apply to return as unprocessable claims:

• CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.

• RARC MA-130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.


• RARC M16 - Alert: See our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.

Effective April 3, 2009, contractors shall deny claims with ICD-9/ICD-10 diagnosis code 185/C61 for FDG PET imaging for the initial treatment strategy of patients with adenocarcinoma of the prostate.

For dates of service prior to June 11, 2013, contractors shall also deny claims for FDG PET imaging for subsequent treatment strategy for tumor types other than breast, cervical, colorectal, esophagus, head and neck (non-CNS/thyroid), lymphoma, melanoma, myeloma, non-small cell lung, and ovarian, unless the FDG PET is provided under CED (submitted with the Q0/Q1 modifier) and use the following messages:

• Medicare Summary Notice 15.4 - Medicare does not support the need for this service or item

• CARC 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.

• Contractors shall use Group Code CO (Contractual Obligation)

If the service is submitted with a GA modifier indicating there is a signed Advance Beneficiary Notice (ABN) on file, the liability falls to the beneficiary. However, if the service is submitted with a GZ modifier indicating no ABN was provided, the liability falls to the provider.

N517, N519, CARC 149 and N587 - Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes

Effective for dates of service on or after September 27, 2013, contractors shall return as unprocessable/return to provider claims for PET Aß imaging, through CED during a clinical trial, not containing the following:


• Condition code 30, (A/B MAC (A) only)

• Modifier Q0 and/or modifier Q1 as appropriate

• ICD-9 dx code V70.7/ICD-10 dx code Z00.6 (on either the primary/secondary position)

• A PET HCPCS code (78811 or 78814)

• At least, one Dx code from the table below,


ICD-9 Codes                                                 Corresponding ICD-10 Codes

290.0 Senile dementia, uncomplicated                                       F03.90 Unspecified dementia without behavioral disturbance

290.10 Presenile dementia, uncomplicated                                 F03.90   Unspecified dementia without behavioral disturbance

290.11 Presenile dementia with delirium                                      F03.90    Unspecified dementia without behavioral disturbance

290.12 Presenile dementia with delusional features                      F03.90    Unspecified dementia without behavioral disturbance

290.13 Presenile dementia with depressive features                    F03.90    Unspecified dementia without behavioral disturbance

290.20 Senile dementia with delusional features                          F03.90    Unspecified dementia without behavioral disturbance

290.21 Senile dementia with depressive features                         F03.90    Unspecified dementia without behavioral disturbance

290.3 Senile dementia with delirium                                            F03.90    Unspecified dementia without behavioral disturbance

290.40 Vascular dementia, uncomplicated                                   F01.50    Vascular dementia without behavioral disturbance

290.41 Vascular dementia with delirium                                       F01.51      Vascular dementia with behavioral disturbance

290.42 Vascular dementia with delusions                                     F01.51       Vascular dementia with behavioral disturbance

290.43 Vascular dementia with depressed mood                         F01.51          Vascular dementia with behavioral disturbance

294.10 Dementia in conditions classified elsewhere without
behavioral disturbance                                                                F02.80  Dementia in other diseases classified elsewhere without                                                                                                  behavioral disturbance

294.11 Dementia in conditions classified elsewhere with
behavioral disturbance                                                               F02.81     Dementia in other diseases classified elsewhere with                                                                                                behavioral disturbance

294.20 Dementia, unspecified, without behavioral disturbance         F03.90     Unspecified dementia without behavioral disturbance

294.21 Dementia, unspecified, with behavioral disturbance            F03.91       Unspecified dementia with behavioral disturbance

331.11 Pick’s Disease                                                                G31.01 Pick's disease


331.19 Other Frontotemporal dementia                                     G31.09 Other frontotemporal dementia

331.6 Corticobasal degeneration                                              G31.85 Corticobasal degeneration

331.82 Dementia with Lewy Bodies                                          G31.83 Dementia with Lewy bodies

331.83 Mild cognitive impairment, so stated                              G31.84 Mild cognitive impairment, so stated


780.93 Memory Loss                                                                  R41.1 Anterograde amnesia
                                                                                                 R41.2 Retrograde amnesia
                                                                                                 R41.3 Other amnesia (Amnesia NOS, Memory loss NOS)

V70.7 Examination for normal comparison or control in clinical         Z00.6   Encounter for examination for normal comparison and                                                                                                   control in clinical research program


and
• Aß HCPCS code A9586 or A9599

Contractors shall return as unprocessable claims for PET Aß imaging using the following messages:

-Claim Adjustment Reason Code 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing.

Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

-Remittance Advice Remark Code N517 - Resubmit a new claim with the requested information.

- Remittance Advice Remark Code N519 - Invalid combination of HCPCS modifiers.

Contractors shall line-item deny claims for PET Aß , HCPCS code A9586 or A9599 , where a previous PET Aß, HCPCS code A9586 or A9599 is paid in history using the following messages:

• CARC 149: “Lifetime benefit maximum has been reached for this service/benefit category.”

• RARC N587: “Policy benefits have been exhausted”.

• MSN 20.12: “This service was denied because Medicare only covers this service once a lifetime.”

• Spanish Version: “Este servicio fue negado porque Medicare sólo cubre este servicio una vez en la vida.”

• Group Code: PR, if a claim is received with a GA modifier

• Group Code: CO, if a claim is received with a GZ modifier

CARC 188, MSN 21.8 - Medicare Summary Notices (MSN), Reason Codes, and Remark Codes

When denying MRI line items on institutional claims when billed with the appropriate MRI code and modifier KX is not present, use the following messages:

If ICD-9-CM is applicable, ICD-9 code V45.01

If ICD-10-CM is applicable, ICD-10 code Z95.0

• CARC 188 – This product/procedure is only covered when used according to the FDA recommendations

• MSN 21.8 – Services performed using equipment that has not been approved by the Food and Drug Administration are not covered. Spanish Version - “Servicios rendidos usando equipo que no es aprobado por la Administración de Alimentos y Drogas no son cubiertos”.

When denying MRI line items on professional claims and modifier KX is not present, use the following messages:

If ICD-9-CM is applicable, ICD-9 code V45.01

If ICD-10-CM is applicable, ICD-10 code Z95.0

• CARC 188 - This product/procedure is only covered when used according to the FDA recommendations

• MSN 21.8 - Services performed using equipment that has not been approved by the Food and Drug Administration are not covered
When denying MRI line items that do not include all of the following line items:

• An appropriate MRI code,

• If ICD-9-CM is applicable, ICD-9 code V45.02 (automatic implantable cardiac defibrillator) or ICD-9 code V45.01 (cardiac pacemaker),

• ICD-10-CM is applicable, ICD-10 code Z95.810 (automatic implantable cardiac defibrillator)or ICD-10 code Z95.0 (cardiac pacemaker),

• Modifier Q0,

• If ICD-9-CM is applicable, ICD-9 code V70.7 Examination of participant in clinical trial (for institutional claims only)or

• If ICD-10-CM is applicable, ICD-10 code Z00.6 – Examination of participant in clinical trial (for institutional claims only), and

• Condition code 30 (for institutional claims only), use the following messages:

o CARC B5 - Coverage/program guidelines were not met or exceeded

o RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.

o MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances. Spanish Version - Este servicio fue denegado porque Medicare solamente lo cubre bajo ciertas circunstancias.

Medical Necessity Denials co 50, 57 ,59 , 151 - Diagnostic Cardiology Services:

Denial Reason, Reason/Remark Code(s)

•    CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD

•    Procedure codes: 93307, 93320, 93325

Resolution/Resources

•    Refer to the 'Transthoracic Echocardiography' Local Coverage Determination

•    If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an Advance Beneficiary Notice (ABN) prior to performing these tests
ABN Information

•    ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'

•    If you utilize ABNs, they must be issued in advance. Maintain a copy in the patient's medical record. Provide the patient with a copy of the signed notice.

•    ABNs must be issued using the standard CMS form. Access the revised ABN and other background information from the CMS website.

•    If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool, which is located under Self Service tools, for information on HCPCS modifier GA.

EKG, EKG Rhythm Strip and Cardiac Echography: NCCI Bundling Denials

Denial Reason, Reason/Remark Code(s)

•    M-80: Not covered when performed during the same session/date as a previously processed service for the patient
•    CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
•    Procedure code: 93010, 93042 and 93320

National Correct Coding Initiative

The National Correct Coding Initiative (NCCI) packages or 'bundles' reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resources

•    Check NCCI edits prior to claim submission; edits are updated quarterly

•    Use the Palmetto GBA NCCI tool to determine if the service you are submitting is bundled with another service

•    Procedure codes 93010 and 93042 are bundled with many Procedure codes including Percutaneous Transluminal Coronary Angioplasty (PTCA), many diagnostic procedures and some other EKG codes

•    Procedure code 93320 is bundled with various codes including Procedure codes 93306, 93307, 93308 and 93018

•    If these services are separate, distinct services and are marked with indicator '1' in the NCCI edit list, submit Procedure modifier 59. Examples of separate, distinct services include situations in which the rhythm strip was taken at a different patient encounter. Supporting documentation is required in the medical records.

•    For additional, specific information on modifiers that may be used to denote exceptions to NCCI (including Procedure modifier 59).


Co 151 - Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Action to be taken : Check the coding edits and act accordingly.
Check the units which was billed
Check the level of service billed
 If we billed with correct information then we have to submit the claim with supporting document.



CO 59 - Processed based on multiple or concurrent procedure rules.
Reason and action: This is Multiple surgeries detected, hence confirm with coding guideliness and take the necessity action. Like...to be written off or to bill with appropriate modifier.


Denial reason code CO 50/PR 50 FAQ

Q: We are receiving a denial with claim adjustment reason code (CARC) CO50/PR50. What steps can we take to avoid this denial code?
These are non-covered services because this is not deemed a “medical necessity” by the payer.

“Medical necessity” assures services are reasonable and necessary for the diagnosis or treatment of illness/injury

A: You are receiving this reason code when the procedure code is billed with an incompatible diagnosis, for payment purposes and the ICD-10 code(s) submitted is not covered under a Local or National Coverage determination (LCD/NCD).
• Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD.
• Provides a guide to assist providers in determining whether a particular item or service is covered and in submitting correct claims for payment.
• LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part.
• Refer to the "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
• Report only the diagnosis(es) for treatment date of service.
• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.
• Be proactive, stay informed on Medicare rules and regulations and maximize the self-service tools on the First Coast website.
• Diagnosis-related denials can be appealed when your documentation supports that a diagnosis from the LCD would apply to your patient’s treatment condition.

EKG code 93010 denied as Duplicate - what should we do

Chest X-ray or EKG: Duplicate Denials

Denial Reason, Reason/Remark Code(s)
•    M-80, CO-18 - Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate
•    Procedure codes: 93010, 71010, 71020

Resolution/Resources
First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA Online Provider Services (OPS) tool or by calling the Palmetto GBA Interactive Voice Response (IVR) unit.

Online Claim Status Verification through OPS
•    All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
•    Access the introductory article to learn more by selecting the 'Introducing Online Provider Services' graphic on the top of any of our main contract Web pages
•    Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
•    Billing services and clearinghouses should contact their provider clients to gain access to the system
•    Specific instructions for accessing claim status information through OPS are available in the OPS User Manual (PDF, 3.6 MB)
Instructions
•    Submit multiple 'identical' services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, use Procedure modifier 76 and specify the exact times of each service.
•    On electronic claims use the documentation record to specify the exact times that each diagnostic service (e.g., chest x-ray, EKG, etc.) was done
•    On electronic claims use the documentation record to explain why more than one diagnostic service was done on the same date by the same provider
•    Attachments (e.g., signed radiology reports, signed EKG reports, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., times):
o    Attachments must be a full page (8 ½ x 11)
•    On appeal signed medical records (e.g., radiology reports, EKG reports, etc.) may be sent as evidence to show why more than one diagnostic service was billed on the same date by same or similar providers from the same group
•    Access specific instructions for documenting and submitting Procedure code modifier 76 through the Palmetto GBA Modifier Lookup. Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.