Chapter I: Online System Terminology
Reason Codes
Purpose
Reason codes direct the outcome of an edit or process within FISS—they are the traffic cops of the system. Each reason code, when assigned, sends the claim to a specific status/location where it resides until further action is taken. This action may be manual (i.e., working a suspended claim) or automatic as when a claim is recycled to the CWF.
There are hundreds of reason codes within FISS. However, the codes that are of importance to providers are those that begin with one of the following digits:
| First Position | Type of Reason Code |
|---|---|
| 1 | CMS unibill editor |
| 3 | FISS application |
| 5 | Medical policy |
| 7 | Customer site-specific |
| C | Crossover reject (CWF) |
| E | Consistency edit reject (CWF) |
| M | Master record at another site (CWF) |
| N | Name/personal characteristic mismatch |
| T | True not in file on CMS batch system |
| U | Utilization reject (CWF) |
| W | FISS Medicare code editor (MCE)/integrated outpatient code editor (IOCE)/Grouper errors |
Once a reason code has been assigned, the claim is routed to the status/location specified by the FISS reason code file. Routing is determined by whether the claim was submitted hard copy or electronically. The reason code file houses all routing information. The following is specific information found within the reason code file and will be of importance to the provider.
- Reason code number
- Effective date
- Status/location for electronic media claims (EMC)
- Status/location for hard-copy claims
- Narrative description
The following screen print illustrates the reason code inquiry file for rejection reason code U5200.
New reason codes, or changes to existing reason codes, are implemented as needed through periodic FISS releases. Providers will be notified of these updates through the Medicare Monthly Review.
Visit the Chapter IV: Inquiries Submenu (01) Reason Codes (17) section of this guide.
Revised 4/15/2018