Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1862 Date: November 27, 2009

Transcription

1 S anual System Pub edicare laims Processing Department of Health & Human Services (DHHS) enters for edicare & edicaid Services (S) Transmittal 1862 Date: November 27, 2009 hange equest 6742 SUBJET: laim djustment eason ode (), emittance dvice emark ode (), and edicare emit Easy Print (EP) Update. SUY O HNGES: This hange equest () instructs contractors to add or modify reason and remark codes that have been added or modified since This also instructs Shared System aintainers (SSs) to deactivate the codes that have been deactivated since 6604, and instructs SSs and ED to accept deactivated codes in derivative messages in some specific situations. dditionally this instructs VPs to update edicare emit Easy Print (EP). This ecurring Update Notification applies to hapter 22, Sections 60.1 and New / evised aterial Effective Date: January 1, 2010 mplementation Date: January 4, 2010 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.. HNGES N NUL NSTUTONS: (N/ if manual is not updated) =EVSED, N=NEW, D=DELETED-Only One Per ow. /N/D hapter / Section / Subsection / Title N/. UNDNG: SETON : or iscal ntermediaries and arriers: No additional funding will be provided by S; contractor activities are to be carried out within their operating budgets. SETON B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. S does not construe this as a change to the Statement 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: 1862 Date: November 27, 2009 hange equest: 6742 SUBJET: laim djustment eason ode (), emittance dvice emark ode (), and edicare emit Easy Print (EP) Update. Effective Date: January 1, 2010 mplementation Date: January 4, GENEL NOTON 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 S staff in conjunction with a policy change. ontractors and Shared System aintainers (SSs) are notified about these changes in the corresponding instructions from the specific S 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 S for a code currently used by edicare, contractors shall use the modified code even though the modification was not initiated by edicare. SSs 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. SSs must make sure that edicare does not report any deactivated code on or before the effective date for deactivation as posted at 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 Stop Date posted on WP Web site because the code list is updated 3 times a year and may not align with the edicare release schedule. Please note that a 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 shall not use 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 will establish the implementation date for all modifications and deactivations for edicare contractors and the SSs. f another specific has been issued by another S component with a different implementation date for a specific deactivation or modification, the earlier of the two dates will apply for edicare implementation. This recurring lists only the changes that have been approved since the last code update, and does not provide a complete list of new/modified/deactivated codes. You must get the complete list for both and from the WP Web site that is updated 3 times a year around arch 1, July 1, and November 1. WP Web site address:

3 The WP Web site has 4 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. laim djustment eason ode (): national code maintenance committee maintains the health care (s). The ommittee meets at the beginning of each X12 trimester meeting (January/ebruary, June and September/October) and makes decisions about additions, modifications, and retirement of existing reason codes. The updated list is posted 3 times a year around early arch, July, and November. To access the list go to: The new codes usually become effective when published. ny modification or deactivation becomes effective on the next quarterly release date (pril 1 or July 1 or October 1 or January 1) or later 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 the next quarterly release date. health plan may decide to implement a code deactivation before the actual effective date posted at WP Web site as long as the deactivated code is allowed to come in on OB claims if the previous payer has 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. ollowing a decision taken by the X work group, edicare is not going to print the additional note with a if the note instructs payers how the specific should be used but will print a note that helps providers. or example: 16 - laim/service lacks information which is needed for adjudication. t least one emark ode must be provided (may be comprised of either the emittance dvice emark ode or NPDP eject eason ode.) Should be printed on the Standard Paper emit or the EP or the P Print as: 16 - laim/service lacks information which is needed for adjudication These are non-covered services because this is not deemed a 'medical necessity' by the payer. This change to be effective 04/01/2010: These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: efer to the 835 E Segment: Healthcare Policy dentification, if present. Should be printed on the Standard Paper emit or the EP or the P Print on or after 4/1/2010 as: 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: efer to the 835 E Segment: Healthcare Policy dentification, if present.

4 New odes : ode urrent Narrative Effective Date per WP Posting 232 nstitutional Transfer mount. Note - pplies to institutional claims 11/1/2009 only and explains the DG amount difference when the patient care crosses multiple institutions.. D23 This dual eligible patient is covered by edicare Part D per edicare etro-eligibility ust also include emittance dvice emark ode 11/1/2009 odified odes : ode odified Narrative Effective Date per WP Posting 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 5 The procedure code/bill type is inconsistent with the place of service. 6 The procedure/revenue code is inconsistent with the patient's age. 7 The procedure/revenue code is inconsistent with the patient's gender. 8 The procedure code is inconsistent with the provider type/specialty (taxonomy). 9 The diagnosis is inconsistent with the patient's age.

5 10 The diagnosis is inconsistent with the patient's gender. 11 The diagnosis is inconsistent with the procedure. 12 The diagnosis is inconsistent with the provider type. 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. 51 These are non-covered services because this is a pre-existing condition. 61 Penalty for failure to obtain second surgical opinion. 96 Non-covered charge(s). 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.) 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. 107 elated or qualifying claim/service was not identified on the claim.

6 108 ent/purchase guidelines were not met. 152 Payer deems the information submitted does not support this length of service. 167 This (these) diagnosis(es) is (are) not covered. 170 Payment is denied when performed/billed by this type of provider. 171 Payment is denied when performed/billed by this type of provider in this type of facility. 172 Payment is adjusted when performed/billed by a provider of this specialty. 179 Patient has not met the required waiting requirements. 183 The referring provider is not eligible to refer the service billed. 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.

7 185 The rendering provider is not eligible to perform the service billed. 222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. B8 lternative services were available, and should have been utilized. B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. 16 laim/service lacks information which is needed for adjudication. 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.) 125 Submission/billing error(s). 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.) 148 nformation from another provider was not provided or was insufficient/incomplete. 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.) 226 nformation requested from the Billing/endering Provider was not provided or was insufficient/incomplete. 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.)

8 227 nformation requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. 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.) 1 laim/service denied. 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.) 40 harges do not meet qualifications for emergent/urgent care. Note: efer to the 835 Healthcare Policy dentification Segment (loop Deactivated odes ode urrent Narrative Effective Date per WP posting 87 Transfer mount. 1/1/2012 D23 This dual eligible patient is covered by edicare Part D per edicare etro-eligibility ust also include emittance dvice emark ode 1/1/2012 emittance dvice emark odes: S is the national maintainer of the remittance advice remark code list. This code list is used by reference in the S X12 N transaction 835 (Health are laim Payment/dvice) version mplementation Guide (G). 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. S 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 S staff in conjunction with a policy change. ontractors are notified about these changes in the corresponding instructions from the specific S 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 S for a code currently used by edicare, contractors shall use the modified code even though the modification was not initiated by edicare. Shared System 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. 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. edicare contractors shall not use any deactivated reason and/or remark code past the deactivation date whether the deactivation is requested by edicare or any other entity. The complete list of remark codes is available at:

9 list is updated 3 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: Published in early arch Deactivation becomes effective in October ny new code or modification become effective when published equest received in ebruary ay: Published in early July Deactivation becomes effective in January ny new code or modification become effective when published equest received in June September: Published in early November Deactivation becomes effective in pril ny new code or any modification becomes effective when published s mentioned earlier, specific S components may publish s in addition to the recurring code update s instructing contractors to use specific 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. By January 4, 2010, contractors shall complete entry of all applicable code text changes and new codes, and the SSs shall implement all code deactivations. ontractors must use the latest approved and valid codes in transaction 835, corresponding Standard Paper emittance (SP) advice, and coordination of benefits transactions. S has developed a new Web site to help navigate the database more easily. tool is provided to help search if you are looking for a specific category of codes. t this site, you can find some other information that is also available from the WP Web site. This S Web site address is: (This Web site is currently being updated, and will be available in early December, 2009) NOTE : This Web site is not replacing the WP Web site as the official site where the most current list resides. f there is any discrepancy, always use the list posted at the WP Web site. NOTE : Some 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 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 that 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 s -16, 96, 125, 148, 226, 227, and 1. New odes : ode urrent Narrative edicare nitiated

10 N521 ismatch between the submitted provider information and the provider information stored in our system. NO N522 Duplicate of a claim processed as a crossover claim. NO odified odes : ode odified Narrative edicare nitiated 39 The patient is not liable for payment for this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. NO 118 Letter to follow containing further information. NO N59 N130 Please refer to your provider manual for additional program and provider information. onsult plan benefit documents/guidelines for information about restrictions for this service. NO NO N202 dditional information/explanation will be sent separately NO Deactivated odes None B. Policy: or 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. dditionally, for transaction 837 OB, must be used. These code sets are updated 3 times a year on a regular basis. edicare contractors shall report only currently valid codes in both the remittance advice and OB laim transaction, and shall allow deactivated and in derivative messages when certain conditions are met (see B segment for explanation of conditions). Shared System aintainers and contractors must make the necessary changes on a regular basis as per this recurring code update 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 have not been initiated by edicare.

11 . BUSNESS EQUEENTS TBLE Use Shall to denote a mandatory requirement Number equirement esponsibility (place an X in each applicable column) /B s, carriers, DE s, s, and HHs shall update reason and remark codes that have been modified and apply to edicare by January 4, / B D E E H H X X X X X Shared-System aintainers V S S S S W OTHE /B s, carriers, DE s, s, and HHs shall update reason and remark codes to include new codes that apply to edicare by January 4, X X X X X SS, S, and VPs 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 January 4, SS, S, VPs shall update any crosswalk between the standard reason and remark codes and the shared system internal codes provided to the contractors and make any deactivated standard code unavailable for use by the contractors by January 4, SS, S, and ED shall make necessary programming changes so that deactivated reason and remark codes are allowed in derivative messages after the deactivation implementation date (January 4, 2010) when: edicare is not primary; the OB claim 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 SS, S, and VPs shall make necessary programming changes so that deactivated reason and remark codes are allowed in derivative messages even after the deactivation implementation date (January 4, 2010) in a eversal and orrection situation when a value of 22 in LP02 identifies the claim to be a corrected claim VPs shall update the edicare emit Easy Print (EP) software to include the most current and lists available from the following Web site: X X X X X X X X ED X X X X

12 Number equirement esponsibility (place an X in each applicable column) (Note: This update is provided in a separate file since pril, 2008.) / B D E E H H Shared-System aintainers V S S S S W OTHE /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 software. X X ED. POVDE EDUTON TBLE Number equirement esponsibility (place an X in each applicable column) 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. / B D E E H H Shared-System aintainers V S S S S W OTHE X X X X ED

13 V. SUPPOTNG NOTON Section : or any recommendations and supporting information associated with listed requirements, use the box below: N/ Use "Should" to denote a recommendation. X-ef ecommendations or other supporting information: equireme nt Number Section B: or all other recommendations and supporting information, use this space: N/ V. ONTTS Pre-mplementation ontact(s): Sumita Sen at sumita.sen@cms.hhs.gov or Post-mplementation ontact(s): Sumita Sen at sumita.sen@cms.hhs.gov or V. UNDNG Section : or iscal ntermediaries (s), egional Home Health ntermediaries (HHs), and/or arriers, use only one of the following statements: No additional funding will be provided by S; contractor activities are to be carried out within their operating budgets. Section B: or edicare dministrative ontractors (s), include the following statement: The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. S does not construe this as a change to the Statement 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.