SUBJECT: Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Medicare Remit Easy Print (MREP) and PC Print Update

Transcription

1 anual ystem Pub edicare laims Processing Department of Health & Human ervices (DHH) enters for edicare & edicaid ervices () Transmittal 2372 Date: December 22, 2011 hange equest 7683 UBJET: laim djustment eason ode (), emittance dvice emark ode (), and edicare emit Easy Print (EP) and P Print Update. UY OF HNGE: This purpose of this hange equest () is to instruct the contractors and the hared ystem aintainers (s) to make programming changes to incorporate new, modified, and deactivated laim djustment eason odes (s) and emittance dvice emark odes (s) that have been added since the last recurring code update. t also instructs Fiscal ntermediary tandard ystem (F) and VPs edicare ystem (V) to update P Print and edicare emit Easy Print (EP) software. EFFETVE DTE: pril 1, 2012 PLEENTTON DTE: pril 2, 2012 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. HNGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED-Only One Per ow. /N/D HPTE / ETON / UBETON / TTLE N/. FUNDNG: For Fiscal ntermediaries (Fs), egional Home Health ntermediaries (HHs) and/or arriers: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. For edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTHENT: ecurring Update Notification *Unless otherwise specified, the effective date is the date of service.

2 ttachment ecurring Update Notification Pub Transmittal: 2372 Date: December 22,2011 hange equest: 7683 UBJET: laim djustment eason ode (), emittance dvice emark ode (), and edicare emit Easy Print (EP) and P Print Update Effective Date: pril 1, 2012 mplementation Date: pril 2, 2012 GENEL NFOTON Background: The Health nsurance Portability and ccountability ct (HP) of 1996, instructs health plans to be able to conduct standard electronic transactions adopted under HP using valid standard codes. edicare policy states that laim djustment eason odes (s) are required in the remittance advice and coordination of benefits transactions. edicare policy further states that appropriate emittance dvice emark odes (s) that provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment are required in the remittance advice transaction. The and changes that impact edicare are usually requested by staff in conjunction with a policy change. ontractors and hared ystem aintainers (s) are notified about these changes in the corresponding instructions from the specific component that implements the policy change, in addition to the regular code update notification. f a modification has been initiated by an entity other than for a code currently used by edicare, contractors must either use the modified code or another code if the modification makes the modified code inappropriate to explain the specific reason for adjustment. s have the responsibility to implement code deactivation making sure that any deactivated code is not used in original business messages, but the deactivated code in derivative messages is allowed. s must make sure that edicare does not report any deactivated code on or before the effective date for deactivation as posted on the WP Web site. ontractors shall stop using codes that have been deactivated on or before the effective date specified in the comment section (as posted on the WP Web site) if they are currently being used. n order to comply with any deactivation, edicare may have to stop using the deactivated code in original business messages before the actual top Date posted on the WP Web site because the code list is updated three times a year and may not align with the edicare release schedule. (Note: deactivated code used in derivative messages must be accepted even after the code is deactivated if the deactivated code was used before the deactivation date by a payer who adjudicated the claim before edicare. ) edicare contractors must stop using any deactivated reason and/or remark code past the deactivation date whether the deactivation is requested by edicare or any other entity. The regular code update hange equest () will establish the implementation date for all modifications, deactivations, and any new code for edicare contractors and the s (see below table for exceptions). f another specific has been issued by another component with a different implementation date, the earlier of the two dates will apply for edicare implementation. f any new or modified code has an effective date past the implementation date specified in this, contractors must implement on the date specified on the WP Web site. ee below for code change implementation exceptions if the implementation date in this recurring (or any other ) does not match the effective date specified at WP Web site: Type of hange mplementation Date esponsible Party

3 Deactivation On or before the date posted at WP Web site s odification On the date posted at WP Web site ontractors/s New On or after the date posted at WP Web site ontractors/s The discrepancy between the dates may arise because the WP Web site gets updated only 3 times a year and may not match the release schedule. This recurring lists only the changes that have been approved since the last code update ( 7514 Transmittal 2304), and does not provide a complete list of codes in these two code sets. You must get the complete list for both and from the WP Web site that is updated three times a year around arch 1, July 1, and November 1 to get the comprehensive lists for both code sets, but the implementation date for any new or modified or deactivated code for edicare contractors is established by this recurring code update published three or four times a year according to the edicare release schedule (see above for exception). WP Web site address: The WP Web site has four listings available for both and : ll: ll codes including deactivated and to be deactivated codes are included in this listing. To Be Deactivated: Only codes to be deactivated at a future date are included in this listing. Deactivated: Only codes with prior deactivation effective date are included in this listing. urrent: Only currently valid codes are included in this listing. NOTE : n case of any discrepancy in the code text as posted on WP Web site and as reported in any, the WP version should be implemented. NOTE : This recurring ode Update lists only the changes approved since the last recurring ode Update once. f any modification becomes effective at a future date, contractors must make sure that they update on the quarterly release date that matches the effective date as posted on the WP Web site. laim djustment eason ode (): national code maintenance committee maintains the health care laim djustment eason odes (s). The ommittee meets at the beginning of each X12 trimester meeting (January/February, June and eptember/october) and makes decisions about additions, modifications, and retirement of existing reason codes. The updated list is posted three times a year around early arch, July, and November. To access the list go to: The new codes usually become effective when approved unless mentioned otherwise. ny modification or deactivation becomes effective on a future date to provide lead time for implementing necessary programming changes. Exception: The effective date for a modification may be as early as the approval or publication date if the requester can provide enough justification to have the modification become effective earlier than a future date. health plan may decide to implement a code deactivation before the actual effective date posted on WP Web site as long as the deactivated code is allowed to come in on oordination of Benefits (OB) claims if the previous payer(s) has (have) used that code prior to the deactivation date. n most cases edicare will stop using a deactivated code before the deactivation becomes effective per the WP Web site to accommodate the edicare release schedule.

4 The following new laim djustment eason odes were approved by the ode ommittee in October, and must be implemented, if appropriate, by pril 2, New odes : ode urrent Narrative Effective Date 238 laim spans eligible and ineligible periods of 3/1/2012 coverage, this is the reduction for the ineligible period (use Group ode P). 239 laim spans eligible and ineligible periods of coverage. ebill separate claims (use Group ode O). 3/1/2012 odified odes : ode odified Narrative Effective Date 18 Exact duplicate claim/service (Use with Group 1/1/2013 ode O). Deactivated odes : ode urrent Narrative Effective Date 141 laim spans eligible and ineligible periods of 7/1/2012 coverage. emittance dvice emark odes (): is the national maintainer of the remittance advice remark code list. This code list is used by reference in the X12 N transaction 835 (Health are laim Payment/dvice) version and mplementation Guide (G)/Technical eport (T) 3. Under HP, all payers, including edicare, have to use reason and remark codes approved by X12 recognized code set maintainers instead of proprietary codes to explain any adjustment in the claim payment. as the X12 recognized maintainer of s receives requests from edicare and non- edicare entities for new codes and modification/deactivation of existing codes. dditions, deletions, and modifications to the code list resulting from non-edicare requests may or may not impact edicare. emark and reason code changes that impact edicare are usually requested by staff in conjunction with a policy change. ontractors are notified about these changes in the corresponding instructions from the specific component which implements the policy change, in addition to the regular code update notification. f a modification has been initiated by an entity other than for a code currently used by edicare, contractors must use the modified code even though the modification was not initiated by edicare. hared ystem aintainers have the responsibility to implement code (both and ) deactivation making sure that any deactivated code is not used in original business messages, but the deactivated code in derivative messages is allowed. The complete list of remark codes is available at: list is updated three times a year in early arch, July and November although the ommittee meets every month. The ommittee has established the following schedule: equest received in October January:

5 Published in early arch Deactivation becomes effective in October ny new code or modification become effective when published equest received in February ay: Published in early July Deactivation becomes effective in January ny new code or modification become effective when published equest received in June eptember: Published in early November Deactivation becomes effective in July ny new code or any modification becomes effective when published NOTE: Exception to the above schedule may be approved by the ommittee if enough justification is provided by the requester for a different effective date. This recurring is published four times a year. odes are updated three times a year, pril, July and October as part of this recurring. The fourth publication in January is usually used to address EP enhancement requests. s mentioned earlier, specific components may publish s in addition to the recurring code update s instructing contractors to use specific s/ s and establishing an implementation date that may differ from the implementation date mentioned in the recurring code update. f there is any difference in the implementation dates, the contractors are to implement on the earlier of the two dates (see table under General nformation for exceptions). By pril 2, 2012, contractors must complete entry of all applicable code text changes and new codes, and the s shall implement all code deactivations, if any. (NOTE: Deactivation decisions made earlier may be included in earlier s consult the complete lists posted at WP Web site. ontractors must use the latest approved and valid laim djustment eason odes and emittance dvice emark odes in the 835 and corresponding tandard Paper emittance (P) advice, and the latest approved and valid laim djustment eason odes in the 837 OB.) NOTE: ome remark codes may only provide general information that may not necessarily supplement the specific explanation provided through a reason code and in some cases another/other remark code(s) for a monetary adjustment. odes that are nformational will have the word lert in the text to identify them as informational rather than explanatory codes. These nformational codes may be used without any specific monetary adjustment and an associated explaining the monetary adjustment. These informational codes should be used only if specific information about adjudication (like appeal rights) needs to be communicated but not as default codes when a is required with a e.g., 16, 96, 125, 129, 148, 226, 227, 234, 1, and D23. New odes : None odified odes : None Deactivated odes :

6 None B. Policy: For transaction 835 (Health are laim Payment/dvice) and standard paper remittance advice, there are two code sets laim djustment eason ode () and emittance dvice emark ode () that must be used to report payment adjustments, appeal rights, and related information. f there is any adjustment, appropriate Group ode must be reported as well. dditionally, for transaction 837 OB, must be used. and code sets are updated three times a year on a regular basis. edicare contractors must report only currently valid codes in both the remittance advice and OB laim transaction, and must allow deactivated and in derivative messages when certain conditions are met (see Business equirements segment for explanation of conditions). hared ystem aintainers and contractors must make the necessary changes on a regular basis as per this recurring code update and/or the specific that describes the change in policy that resulted in the code change requested by edicare. ny modification and/or deactivation will be implemented by edicare even when the modification and/or the deactivation has not been initiated by edicare.. BUNE EQUEENT TBLE Number equirement esponsibility (place an X in each applicable column) / D F hared- ystem OTHE B E aintainers ontractors shall update reason and remark codes that have been modified and apply to edicare by pril 2, NOTE: ome modifications may become effective at a future date. ontractors shall make sure that modifications are implemented on the effective date as posted on the WP Web site (which may be later than the implementation date mentioned in this ) for those code modifications that are being used by edicare. E H H X X X X X F V W F ontractors shall update reason and remark codes to include new codes that apply to edicare by pril 2, 2012 or after pril 2, 2012 if instructed by. X X X X X NOTE: ome new codes may become effective at a future date. ontractors shall make sure that new codes are implemented, if directed by, on the effective date or later as posted on the WP Web site F,, and V shall make necessary programming changes so that no deactivated reason and remark code is reported in the remittance advice and no deactivated reason code is reported in the OB claim by pril 2, X X X

7 Number equirement esponsibility (place an X in each applicable column) / D F hared- ystem OTHE B E aintainers E H H F V W F NOTE: heck the updated lists as posted on the WP Web site to capture deactivations that were included in previous (s) F,, and V shall make sure that no deactivated code in the attached list of deactivated and codes is being reported on the remittance advice and the 837OB if applicable on or before pril 2, X X X ttachment for Deactivated List of s ttachment for Deactivated List of s F,, V shall update any crosswalk between the standard reason and remark codes and the shared system internal codes provided to the contractors and make any standard code deactivated since the last update unavailable for use by the contractor by pril 2, X X X F,, ED shall make necessary programming changes so that deactivated reason and remark codes are allowed in derivative messages after the deactivation implementation date per this or as posted on the WP Web site when: edicare is not primary; The OB claims is received after the deactivation effective date; and The date in DTP03 in Loop 2430 or 2330B in OB 837 transaction is less than the deactivation effective date as posted on the WP Web site. X X F,, and V shall make necessary programming X X X changes so that deactivated reason and remark codes are allowed even after the deactivation implementation date in a eversal and orrection situation when a value of 22 in LP02 identifies the claim to be a corrected claim V shall update the edicare emit Easy Print X (EP) software by pril 2, This update shall be based on the and lists as posted on WP Web site on or around NOTE: This update is provided in a separate file since pril, F shall update the P Print software by pril 2, X ED

8 Number equirement esponsibility (place an X in each applicable column) / D F hared- ystem OTHE B E aintainers This update shall be based on the and lists as posted on WP Web site on or around E H H F V W F /B s, carriers, and ED for DE s shall notify the users that the code update file must be downloaded to be used in conjunction with the updated EP/P Print software. X X ED. POVDE EDUTON TBLE Number equirement esponsibility (place an X in each applicable column) / D F hared- ystem OTHE B E aintainers provider education article related to this instruction will be available at shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. E H H X X X X X F V W F ED V. UPPOTNG NFOTON ection : For any recommendations and supporting information associated with listed requirements, use the box below: N/

9 X-ef equireme nt Number ecommendations or other supporting information: N/ ection B: For all other recommendations and supporting information, use this space: N/ V. ONTT Pre-mplementation ontact(s): umita en at or Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. FUNDNG ection : For Fiscal ntermediaries (Fs), egional Home Health ntermediaries (HHs), and/or arriers: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: For edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTHENT (2) ttachment : laim djustment eason odes - Deactivated and To Be Deactivated ttachment : emittance dvice emark odes - Deactivated and To Be Deactivated

10 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description 17 equested information was not provided or was insufficient/incomplete. t least one emark ode must be provided (may be comprised of either the emittance dvice emark ode or NPDP eject eason ode.) tart: 01/01/1995 Last odified: 09/21/2008 top: 07/01/2009 Payment denied. Your top loss deductible has not been met. tart: 01/01/1995 top: 04/01/2008 overage not in effect at the time the service was provided. 30 Notes: edundant to codes 26&27. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements tart: 01/01/1995 top: 02/01/2006 Balance does not exceed co-payment amount. Balance does not exceed deductible. Discount agreed to in Preferred Provider contract. harges exceed our fee schedule or maximum allowable amount. (Use 45) tart: 01/01/1995 Last odified: 10/31/2006 top: 06/01/2007 Gramm-udman reduction. 46 tart: 01/01/1995 top: 07/01/2006 This (these) service(s) is (are) not covered. 1

11 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description Notes: Use code 96. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. tart: 01/01/1995 top: 02/01/2006 This (these) procedure(s) is (are) not covered Notes: Use code 96. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. tart: 01/01/1995 top: 02/01/2006 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. tart: 01/01/1995 top: 06/30/ Notes: plit into codes 150, 151, 152, 153 and 154. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. tart: 01/01/1995 Last odified: 10/31/2006 top: 04/01/2007 orrection to a prior claim. Denial reversed per edical eview. Procedure code was incorrect. This payment reflects the correct code. 2

12 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description 67 Lifetime reserve days. (Handled in QTY, QTY01=L) DG weight. (Handled in LP12) Primary Payer amount. tart: 01/01/1995 top: 06/30/ Notes: Use code 23. oinsurance day. (Handled in QTY, QTY01=D) dministrative days. overed days. (Handled in QTY, QTY01=) ost eport days. (Handled in 15) Outlier days. (Handled in QTY, QTY01=OU) Discharges. PP days. 3

13 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description Total visits. apital djustment. (Handled in ) tatutory djustment Notes: Duplicative of code 45. djustment amount represents collection against receivable created in prior overpayment. tart: 01/01/1995 top: 06/30/2007 laim Paid in full. No laim level djustments Notes: s of , at the claim level is optional. The hospital must file the edicare claim for this inpatient non-physician service. edicare econdary Payer djustment mount. Payment denied because service/procedure was provided outside the United tates or as a result of war. 4

14 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description tart: 01/01/1995 Last odified: 02/28/2001 top: 06/30/ Notes: Use odes 157, 158 or 159. Patient is covered by a managed care plan. tart: 01/01/1995 top: 06/30/ Notes: Use code 24. Payer refund due to overpayment. tart: 01/01/1995 top: 06/30/ Notes: efer to implementation guide for proper handling of reversals. Payer refund amount - not our patient. tart: 01/01/1995 Last odified: 06/30/1999 top: 06/30/ Notes: efer to implementation guide for proper handling of reversals. Deductible -- ajor edical tart: 02/28/1997 Last odified: 09/30/2007 top: 04/01/ Notes: Use Group ode P and code 1. oinsurance -- ajor edical tart: 02/28/1997 Last odified: 09/30/2007 top: 04/01/ Notes: Use Group ode P and code 2. Premium payment withholding tart: 06/30/2002 Last odified: 09/30/2007 top: 04/01/2008 Notes: Use Group ode O and code 45. 5

15 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description 156 Flexible spending account payments. Note: Use code tart: 09/30/2003 Last odified: 01/25/2009 top: 10/01/2009 laim/service denied based on prior payer's coverage determination. tart: 06/30/2006 top: 02/01/ Notes: Use code 136. ontractual adjustment. tart: 01/01/1995 Last odified: 02/28/2007 top: 01/01/ B2 B3 B6 Notes: Use ode 45 with Group ode 'O' or use another appropriate specific adjustment code. edicare econdary Payer liability met. edicare laim PP apital Day Outlier mount. tart: 01/01/1995 Last odified: 09/30/2007 top: 04/01/2008 overed visits. overed charges. This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. B17 tart: 01/01/1995 top: 02/01/2006 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. tart: 01/01/1995 top: 02/01/2006 6

16 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description B18 This procedure code and modifier were invalid on the date of service. B19 B21 D1 tart: 01/01/1995 Last odified: 09/21/2008 top: 03/01/2009 laim/service adjusted because of the finding of a eview Organization. The charges were reduced because the service/care was partially furnished by another physician. laim/service denied. Level of subluxation is missing or inadequate. D2 Notes: Use code 16 and remark codes if necessary. laim lacks the name, strength, or dosage of the drug furnished. D3 Notes: Use code 16 and remark codes if necessary. laim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. D4 Notes: Use code 16 and remark codes if necessary. laim/service does not indicate the period of time for which this will be needed. D5 Notes: Use code 16 and remark codes if necessary. laim/service denied. laim lacks individual lab codes included in the test. 7

17 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description D6 Notes: Use code 16 and remark codes if necessary. laim/service denied. laim did not include patient's medical record for the service. D7 Notes: Use code 16 and remark codes if necessary. laim/service denied. laim lacks date of patient's most recent physician visit. D8 Notes: Use code 16 and remark codes if necessary. laim/service denied. laim lacks indicator that 'x-ray is available for review.' D9 Notes: Use code 16 and remark codes if necessary. laim/service denied. laim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. D10 Notes: Use code 16 and remark codes if necessary. laim/service denied. ompleted physician financial relationship form not on file. D11 Notes: Use code 17. laim lacks completed pacemaker registration form. D12 Notes: Use code 17. laim/service denied. laim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. 8

18 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description D13 Notes: Use code 17. laim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. D14 Notes: Use code 17. laim lacks indication that plan of treatment is on file. D15 Notes: Use code 17. laim lacks indication that service was supervised or evaluated by a physician. D16 Notes: Use code 17. laim lacks prior payer payment information. tart: 01/01/1995 top: 06/30/2007 D17 Notes: Use code 16 with appropriate claim payment remark code [N4]. laim/ervice has invalid non-covered days. tart: 01/01/1995 top: 06/30/2007 D18 Notes: Use code 16 with appropriate claim payment remark code. laim/ervice has missing diagnosis information. tart: 01/01/1995 top: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code. 9

19 laim djustment eason odes - Deactivated and To Be Deactivated ode (s of 11/1/2011) Description D19 laim/ervice lacks Physician/Operative or other supporting documentation tart: 01/01/1995 top: 06/30/2007 D20 Notes: Use code 16 with appropriate claim payment remark code. laim/ervice missing service/product information. tart: 01/01/1995 top: 06/30/2007 D21 D22 Notes: Use code 16 with appropriate claim payment remark code. This (these) diagnosis(es) is (are) missing or are invalid tart: 01/01/1995 top: 06/30/2007 Workers' ompensation only) - Temporary code to be added for timeframe only until 01/01/2009. nother code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code tart: 01/27/2008 top: 01/01/2009 TO BE DETVTED D23 Transfer amount. tart: 01/01/1995 Last odified: 09/20/2009 top: 01/01/2012 laim spans eligible and ineligible periods of coverage. tart: 06/30/1999 Last odified: 09/30/2007 top: 07/01/2012 This dual eligible patient is covered by edicare Part D per edicare etro-eligibility. t least one emark ode must be provided (may be comprised of either the NPDP eject eason ode, or emittance dvice emark ode that is not an LET.) tart: 11/01/2009 top: 01/01/

20 ttachment For lternate format, please contact the author emittance dvice emark odes - Deactivated and To Be Deactivated (s of Last Effective Deactivation ode Description odified Notes Date Date Date 72 Did not enter full 8-digit date (/DD/YY). 01/01/ /16/2003 onsider using ncorrect admission date patient status or type of bill entry on claim. 01/01/ /16/2003 onsider using 30, 40 or 43 laim ejected. Does not contain the correct edicare anaged are 98 Demonstration contract number for this beneficiary. 01/01/ /16/2003 onsider using 97 N41 uthorization request denied. 01/01/ /16/2003 onsider using eason ode 39 N44 Payer s share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority. 01/01/ /16/2003 onsider using eason ode not otherwise classified or unlisted procedure code(s) was billed but a narrative description of the procedure was not entered on the claim. efer to item 19 on the HF /01/ /01/2004 (Deactivated 2/28/2003) (Erroneous description corrected 9/2/2008) onsider 02/28/2003 using ervice not covered until after the patient s 50th birthday, i.e., no coverage prior to the day after the 50th birthday 01/01/ /30/2004 onsider using Payment for this service previously issued to you or another provider by another carrier/intermediary. 01/01/ /31/2004 onsider using eason ode Payment for services furnished to hospital inpatients (other than professional services of physicians) can only be made to the hospital. You must request payment from the hospital rather than the patient for this service. 01/01/ /31/2004 onsider using We do not pay for more than one of these on the same day. 01/01/ /31/2004 onsider using Begin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN. 01/01/ /31/2004 onsider using Begin to report a G1-G5 modifier with this HP. We will soon begin to deny payment for this service if billed without a G1-G5 modifier. 01/01/ /31/2004 onsider using nformation supplied does not support a break in therapy. new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service. 01/01/ /31/2004 onsider using 31

21 11 Payment is being issued on a conditional basis. f no-fault insurance, liability insurance, Workers' ompensation, Department of Veterans ffairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources. 01/01/ /31/2004 onsider using The patient overpaid you. You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient. 01/01/ /31/2004 onsider using issing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician. 01/01/ /31/2004 onsider using 128 or Processed for E only. 01/01/ /31/2004 onsider using eason ode This provider was not certified for this procedure on this date of service. 10/12/ /31/ /31/2004 onsider using 120 and eason ode B7 N18 Payment based on the edicare allowed amount. 01/01/ /31/2004 onsider using N14 N60 valid ND is required for payment of drug claims effective October /01/ /31/2004 onsider using 119 N73 killed Nursing Facility is responsible for payment of outside providers who furnish these services/supplies under arrangement to its residents. 01/01/ /31/2004 onsider using 101 or N200 N101 dditional information is needed in order to process this claim. Please resubmit the claim with the identification number of the provider where this service took place. The edicare number of the site of service provider should be preceded with the letters 'HP' and entered into item #32 on the claim form. You may bill only one site of service provider number per claim. 10/31/ /31/2004 onsider uisng 105 N164 Transportation to/from this destination is not covered. 02/28/ /31/2004 onsider using N157 N165 Transportation in a vehicle other than an ambulance is not covered. 02/28/ /31/2004 onsider using N158) N166 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. 02/28/ /31/2004 onsider using N159 N168 The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service. 02/28/ /31/2004 onsider using N160 N169 This drug/service/supply is covered only when the associated service is covered. 02/28/ /31/2004 onsider using N issing/incomplete/invalid UPN for the ordering/referring/performing provider. 01/01/ /01/2004 onsider using laim lacks the L certification number. 01/01/ /01/2004 onsider using We cannot pay for laboratory tests unless billed by the laboratory that did the work. 01/01/ /01/2004 onsider using eason ode B20

22 92 ervices subjected to review under the Home Health edical eview nitiative. 01/01/ /01/ issing/incomplete/invalid beginning and/or ending date(s). 01/01/ /01/2004 onsider using issing/incomplete/invalid six-digit provider identifier for home health agency or hospice for physician(s) performing care plan oversight services. 01/01/ /01/2004 onsider using Our records indicate that a primary payer exists (other than ourselves); however, you did not complete or enter accurately the insurance plan/group/program name or identification number. Enter the PlanD when effective. 01/01/ /01/2004 onsider using issing/incomplete/invalid group or policy number of the insured for the primary coverage. 01/01/ /01/2004 onsider using issing/incomplete/invalid insured's name for the primary payer. 01/01/ /01/2004 onsider using issing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider. 01/01/ /01/2004 onsider using 68 N17 Per admission deductible. 01/01/ /01/2004 onsider using eason ode 1 35 issing/incomplete/invalid pre-operative photos or visual field results. 01/01/ /05/2005 onsider using N issing/incomplete/invalid claim information. esubmit claim after corrections. 01/01/ /05/ issing/incomplete/invalid L certification number for laboratory services billed by physician office laboratory. 01/01/ /05/2005 onsider using 120 N38 issing/incomplete/invalid place of service. 01/01/ /05/2005 onsider using 77 N66 issing/incomplete/invalid documentation. 01/01/ /05/2005 onsider using N29 or N issing/incomplete/invalid provider identifier. 01/01/ /02/ issing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification. 01/01/ /02/ issing/incomplete/invalid provider identifier for the provider who interpreted the diagnostic test. 01/01/ /02/ issing/incomplete/invalid provider identifier for the provider from whom you purchased interpretation services. 01/01/ /02/ issing/incomplete/invalid provider identifier for the substituting physician who furnished the service(s) under a reciprocal billing or locum tenens arrangement. 01/01/ /02/ issing/incomplete/invalid date of the patient s last physician visit. 01/01/ /02/ issing/incomplete/invalid provider name, city, state, or zip code. 01/01/ /02/ issing/incomplete/invalid birth date. 01/01/ /02/2005

23 52 issing/incomplete/invalid date. 01/01/ /02/ issing/incomplete/invalid provider/supplier billing number/identifier or billing name, address, city, state, zip code, or phone number. 01/01/ /02/ issing/incomplete/invalid provider number for this place of service. 01/01/ /02/ eserved for future use. 10/12/ /02/2005 N145 issing/incomplete/invalid provider identifier for this place of service. 10/31/ /02/ issing/incomplete/invalid HP modifier. 01/01/ /18/ /28/2003 (odified 2/28/03,) onsider using eason ode 4 03 N14 N361 f you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing within six months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been denied, including reopened appeals if you received a revised decision. You must appeal each claim on time. 01/01/ /01/2006 onsider using 02 (odified 10/31/02, 11/18/2005 6/30/03, 8/1/05, 11/18/05) Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount. 01/01/ /01/2007 onsider using eason ode 45 Payment adjusted based on multiple diagnostic imaging procedure (odified 12/1/06) onsider using eason rules 11/18/ /01/ /01/2006 ode Provider level adjustment for late claim filing applies to this claim. 01/01/ /01/ /05/2007 onsider using eason ode B4 N411 This service is allowed one time in a 6-month period. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009 N412 This service is allowed 2 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009 N413 N414 N415 This service is allowed 2 times in a benefit year. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009 This service is allowed 4 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009 This service is allowed 1 time in an 18-month period. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009

24 N416 N417 N515 This service is allowed 1 time in a 3-year period. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009 This service is allowed 1 time in a 5-year period. (This temporary code will be deactivated on 2/1/09. ust be used with eason ode 119.) 08/01/ /01/2009 lert: ubmit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. (use N387 instead) 11/01/ /01/ Letter to follow containing further information. 01/01/ /01/ /01/2009 onsider using N N201 N514 killed Nursing Facility (NF) is responsible for payment of outside providers who furnish these services/supplies to residents. 01/01/ /01/ /30/2003 onsider using N538 mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents. 02/25/ /01/2011 onsider using N538 onsult plan benefit documents/guidelines for information about restrictions for this service. 11/01/ /01/2011 onsider using N130