Medicare Monthly Review:Remittance Advice Remark Code/Claim Adjust Reason Code Update (CR5942)

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IssueMonthyear

Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update

Provider Types Affected

Physicians, providers, and suppliers who submit claims to Medicare contractors (carriers, fiscal intermediaries (FI), regional home health intermediaries (RHHI), Part A/B Medicare Administrative Contractors (A/B MAC), durable medical equipment Medicare Administrative Contractors (DME MACs)) for services

Provider Action Needed

CR 5942, from which this article is taken, announces the latest update of Remittance Advice Remark Codes (RARC) and Claim Adjustment Reason Codes (CARC), effective April 1, 2008. Be sure billing staff are aware of these changes.

Background

Two code sets—the reason and remark code sets—must be used to report payment adjustments in remittance advice transactions. The reason codes are also used in some coordination-of-benefits (COB) transactions. The RARC list is maintained by the Centers for Medicare & Medicaid Service (CMS), and used by all payers; and additions, deactivations, and modifications to it may be initiated by any health care organization. The CARC list is maintained by a national Code Maintenance committee that meets when X12 meets for their trimester meetings to make decisions about additions, modifications, and retirement of existing reason codes.

Both code lists are updated three times a year, and are posted at http://www.wpc-edi.com/Codes on the Internet. The lists at the end of this article summarize the latest changes to these lists, as announced in CR 5942.

CMS has also developed a new tool to help you search for a specific category of code and that tool is available at http://www.cmsremarkcodes.info on the Internet. Note that this Web site does not replace the WPC site and, should there be any discrepancies in what is posted at this site and the WPC site; consider the WPC site to be correct.

Additional Information

To see the official instruction (CR5942) issued to your Medicare carrier, RHHI, DME/MAC, FI and/or A/B MAC refer to http://www.cms.hhs.gov/Transmittals/downloads/R1475CP.pdf on the CMS Web site.

For additional information about Remittance Advice, please refer to Understanding the Remittance Advice (RA): A Guide for Medicare Providers, Physicians, Suppliers, and Billers at http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, RHHI, DME/MAC, FI, and/or A/B MAC at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Remittance Advice Remark Code Changes

New Codes

Code	Current Narrative	Medicare Initiated
N430	Procedure code is inconsistent with the units billed. Start: 11/5/2007 Note: (New Code 11/5/07)	YES
N431	Service is not covered with this procedure. Start: 11/5/2007 Note: (New Code 11/5/07)	YES
N432	Adjustment based on a Recovery Audit. Start: 11/5/2007 Note: (New Code 11/5/07)	YES

Modified Codes

Code	Current Modified Narrative	Last Modification Date
M25	The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.	11/5/2007
M26	The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service/any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice. The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office.	11/5/2007
M75	Multiple automated multi-channel tests performed on the same day combined for payment.	11/5/2007
M112	Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.	11/5/2007
M113	Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.	11/5/2007
M114	This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.	11/5/2007
M115	This item is denied when provided to this patient by a non-contract or non-demonstration supplier.	11/5/2007
N70	Consolidated billing and payment applies.	11/5/2007
N367	Alert: The claim information has been forwarded to a Consumer Account Fund processor for review.	11/5/2007
N377	Payment based on a processed replacement claim.	11/5/2007
N385	Notification of admission was not timely according to published plan procedures.	11/5/2007

Deactivated Codes

Code	Current Narrative	Modification Date
MA119	Provider level adjustment for late claim filing applies to this claim. Start: 1/1/1997 \| Stop: 5/1/2008 \| Last Modified: 11/5/2007 Note: (Deactivated eff. 5/1/08) Consider using Reason Code B4.)	Deactivated eff. 5/1/08

Claim Adjustment Reason Codes

New Codes

Code	Current Narrative	Implementation Date
212	Administrative surcharges are not covered Start: 11/05/2007	11/05/2007

Modified Codes

Code	Modified Narrative		Implementation Date
121	Indemnification adjustment - compensation for outstanding member responsibility. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
192	Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Copayment. Start: 10/31/2005 \| Last Modified: 09/30/2007		4/1/2008
206	National Provider Identifier - missing. Start: 07/09/2007 \| Last Modified: 09/30/2007		4/1/2008
207	National Provider identifier - Invalid format Start: 07/09/2007 \| Stop: 05/23/2008 \| Last Modified: 09/30/2007		4/1/2008
208	National Provider Identifier - Not matched. Start: 07/09/2007 \| Last Modified: 09/30/2007		4/1/2008
15	The authorization number is missing, invalid, or does not apply to the billed services or provider. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
17	Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
19	This is a work-related injury/illness and thus the liability of the Workers’ Compensation Carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
20	This injury/illness is covered by the liability carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
21	This injury/illness is the liability of the no-fault carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
22	This care may be covered by another payer per coordination of benefits. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
23	The impact of prior payer(s) adjudication including payments and/or adjustments. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
24	Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
31	Patient cannot be identified as our insured. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
33	Insured has no dependent coverage. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
34	Insured has no coverage for newborns. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
55	Procedure/treatment is deemed experimental/investigational by the payer. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
56	Procedure/treatment has not been deemed “proven to be effective” by the payer. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
59	Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
61	Penalty for failure to obtain second surgical opinion. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
95	Plan procedures not followed. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
107	The related or qualifying claim/service was not identified on this claim. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
108	Rent/purchase guidelines were not met. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
112	Service not furnished directly to the patient and/or not documented. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
115	Procedure postponed, canceled, or delayed. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
116	The advance indemnification notice signed by the patient did not comply with requirements. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
117	Transportation is only covered to the closest facility that can provide the necessary care. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
118	ESRD network support adjustment. Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
125	Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 \| Last Modified: 09/30/2007		4/1/2008
129		Prior processing information appears incorrect. Start: 02/28/1997 \| Last Modified: 09/30/2007	4/1/2008
135		Interim bills cannot be processed. Start: 10/31/1998 \| Last Modified: 09/30/2007	4/1/2008
136		Failure to follow prior payer’s coverage rules. (Use Group Code OA). Start: 10/31/1998 \| Last Modified: 09/30/2007	4/1/2008
137		Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Start: 02/28/1999 \| Last Modified: 09/30/2007	4/1/2008
138		Appeal procedures not followed or time limits not met. Start: 06/30/1999 \| Last Modified: 09/30/2007	4/1/2008
141		Claim spans eligible and ineligible periods of coverage. Start: 06/30/1999 \| Last Modified: 09/30/2007	4/1/2008
142		Monthly Medicaid patient liability amount. Start: 06/30/2000 \| Last Modified: 09/30/2007	4/1/2008
146		Diagnosis was invalid for the date(s) of service reported. Start: 06/30/2002 \| Last Modified: 09/30/2007	4/1/2008
148		Information from another provider was not provided or was insufficient/incomplete. Start: 06/30/2002 \| Last Modified: 09/30/2007	4/1/2008
150		Payer deems the information submitted does not support this level of service. Start: 10/31/2002 \| Last Modified: 09/30/2007	4/1/2008
151		Payer deems the information submitted does not support this many services. Start: 10/31/2002 \| Last Modified: 09/30/2007	4/1/2008
152		Payer deems the information submitted does not support this length of service. Start: 10/31/2002 \| Last Modified: 09/30/2007	4/1/2008
153		Payer deems the information submitted does not support this dosage. Start: 10/31/2002 \| Last Modified: 09/30/2007	4/1/2008
154		Payer deems the information submitted does not support this day’s supply. Start: 10/31/2002 \| Last Modified: 09/30/2007	4/1/2008
155		Patient refused the service/procedure. Start: 06/30/2003 \| Last Modified: 09/30/2007	4/1/2008
157		Service/procedure was provided as a result of an act of war. Start: 09/30/2003 \| Last Modified: 09/30/2007	4/1/2008
158		Service/procedure was provided outside of the United States. Start: 09/30/2003 \| Last Modified: 09/30/2007	4/1/2008
159		Service/procedure was provided as a result of terrorism. Start: 09/30/2003 \| Last Modified: 09/30/2007	4/1/2008
160		Injury/illness was the result of an activity that is a benefit exclusion. Start: 09/30/2003 \| Last Modified: 09/30/2007	4/1/2008
163		Attachment referenced on the claim was not received. Start: 06/30/2004 \| Last Modified: 09/30/2007	4/1/2008
164		Attachment referenced on the claim was not received in a timely fashion. Start: 06/30/2004 \| Last Modified: 09/30/2007	4/1/2008
165		Referral absent or exceeded. Start: 10/31/2004 \| Last Modified: 09/30/2007	4/1/2008
168		Service(s) have been considered under the patient’s medical plan. Benefits are not available under this dental plan. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
169		Alternate benefit has been provided. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
173		Service was not prescribed by a physician. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
174		Service was not prescribed prior to delivery. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
175		Prescription is incomplete. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
176		Prescription is not current. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
177		Patient has not met the required eligibility requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
178		Patient has not met the required spend down requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
179		Patient has not met the required waiting requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
180		Patient has not met the required residency requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
181		Procedure code was invalid on the date of service. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
182		Procedure modifier was invalid on the date of service. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
186		Level of care change adjustment. Start: 06/30/2005 \| Last Modified: 09/30/2007	4/1/2008
191		Not a work related injury/illness and thus not the liability of the Workers’ Compensation carrier. Start: 10/31/2005 \| Last Modified: 09/30/2007	4/1/2008
194		Anesthesia performed by the operating physician, the assistant surgeon, or the attending physician. Start: 02/28/2006 \| Last Modified: 09/30/2007	4/1/2008
195		Refund issued to an erroneous priority payer for this claim/service. Start: 02/28/2006 \| Last Modified: 09/30/2007	4/1/2008
197		Precertification/authorization/notification absent. Start: 10/31/2006 \| Last Modified: 09/30/2007	4/1/2008
198		Precertification/authorization exceeded. Start: 10/31/2006 \| Last Modified: 09/30/2007	4/1/2008
202		Precertification/authorization exceeded. Start: 10/31/2006 \| Last Modified: 09/30/2007	4/1/2008
203		Discontinued or reduced service. Start: 02/28/2007 \| Last Modified: 09/30/2007	4/1/2008
A8		Ungroupable DRG. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B5		Coverage/program guidelines were not met or were exceeded. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B8		Alternative services were available, and should have been utilized. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B9		Patient is enrolled in a Hospice. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B14		Only one visit or consultation per physician per day is covered. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B15		This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B16		`New Patient’ qualifications were not met. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B18		This procedure code and modifier were invalid on the date of service. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B20		Procedure/service was partially or fully furnished by another provider. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008
B23		Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Start: 01/01/1995 \| Last Modified: 09/30/2007	4/1/2008

Deactivated Codes

Code	Current Narrative	Implementation Date
25	Payment denied. Your Stop loss deductible has not been met. Start: 01/01/1995 \| Stop: 04/01/2008	4/1/2008
126	Deductible -- Major Medical Start: 02/28/1997 \| Stop: 04/01/2008 \| Last Modified: 09/30/2007 Notes: Use Group Code PR and code 1.	4/1/2008
127	Coinsurance -- Major Medical Start: 02/28/1997 \| Stop: 04/01/2008 \| Last Modified: 09/30/2007 Notes: Use Group Code PR and code 2.	4/1/2008
145	Premium payment withholding Start: 06/30/2002 \| Stop: 04/01/2008 \| Last Modified: 09/30/2007 Notes: Use Group Code CO and code 45.	4/1/2008
A4	Medicare Claim PPS Capital Day Outlier Amount. Start: 01/01/1995 \| Stop: 04/01/2008 \| Last Modified: 09/30/2007	4/1/2008

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