Thursday, May 24, 2018

What is content of service

CONTENT OF SERVICE

Content of service refers to specific services and/or procedures that are considered to be an integral part of previous or concomitant services or procedures to the extent that separate reimbursement is not recognized. Not all content of service issues are identified in the policies and procedures. BCBSKS staff may identify and classify specific coding and nomenclature issues as they arise. Examples of services that can be considered content of service are:


• Examination of the patient.
• History of illness and/or review of patient records.
• Evaluation of tests or studies (i.e., radiology or pathology).
• Any entries into the patient's records.
• Evaluation of reports of tests or studies earlier referred to another physician for an opinion and subsequently returned for use in the office visit being conducted.
• Advice or information provided during or in association with the visit.
• Case management.
• The prescription of any medicinals, home supplies or equipment during or as a result of the visit.
• The application or the re-application of any standard dressing during a visit.
• Therapeutic, prophylactic, or diagnostic injection administration provided on the same day as an office visit, home visit, or nursing home visit.
• Additional charges beyond the regular charge for services requested after office hours, holidays or in an emergency situation.
• Items of office overhead such as malpractice insurance, telephones, personnel, supplies, cleaning, disinfectants, photographs, equipment sterilization, etc.
• Telephone calls and web-based correspondence are content of service when billed with another service on the same day. Such services are not covered if billed separately and the only service rendered on that day.
• Anesthesia provided in an office setting is considered content of service and not reimbursed separately. The provider cannot require the patient to sign a waiver or bill the patient for this service.
Some content of service issues related to specific services and/or procedures are identified throughout the policy and procedure documents.

NOTE: All-inclusive procedure codes must be used when available.


PATIENT-DEMANDED SERVICES

A. If a provider prescribes services that he knows will not be covered because of a lack of medical necessity or the procedure being considered is experimental or investigational and he alerts the patient of the non-coverage, yet the patient still insists on the services, the provider may bill the patient if the request is properly documented and signed by the member. (See Section X. WAIVER FORM)

B. Providers must obtain a waiver on any mental health consultation, testing, or evaluation that is performed by agreement or at the direction of a court for the purpose of assessing custody, visitation, parental rights, or to determine damages of any kind of personal injury action and if the service is not otherwise medically necessary. To enable the provider to bill a patient for such services, BCBSKS will deny benefits for such services as lacking medical necessity.

Wednesday, December 6, 2017

icd 10 code for insomnia F51.02, F51.01

Surgical Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS) 

Uvulopalatopharyngoplasty (UPPP) may be considered medically necessary for the treatment of clinically significant obstructive sleep apnea syndrome (OSA) in appropriately selected adult patients who have not responded to or do not tolerate nasal continuous positive airway pressure (CPAP). Clinically significant OSA in this case is defined as those patients who have:

• Apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour, or

• AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA), may be considered medically necessary in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP. Clinically significant OSA in this case is defined as those patients who have:

• AHI or RDI greater than or equal to 15 events per hour, or

• AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

CPAP (E0601) may be considered medically necessary for:

• Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than fifteen, or

• Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than five and any of the following associated symptoms:

Excessive daytime sleepiness

Impaired cognition

Mood disorders

Insomnia

Documented hypertension

Ischemic heart disease

History of stroke

• Patients who do not have sleep apnea, but who have restrictive lung disease and documented desaturation at night, requiring nocturnal ventilation

• Under individual consideration APAP may be allowed in selective patients in lieu of repeated CPAP titration when the attending sleep center physician indicates that, in his/her opinion the member would be a suitable candidate for this approach based upon member’s knowledge, behavior, and health status.

Diagnosis of OSA with abnormal Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)

1. AHI or RDI =15; Or

2. AHI or RDI between 5 and 14 (requires one)

a. Excessive daytime sleepiness (ESS)

b. Impaired cognition

c. Insomnia

d. Mood disorder

e. Hypertension;

MSLT is considered not medically necessary in the following four situations:

• When performed for routine diagnosis of obstructive sleep apnea; OR

• For routine follow-up after treatment of sleep related disorders; OR

• For evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia), including, but not limited to, insomnia,
circadian rhythm disorders, and Shift Work Sleep Disorder (SWSD); OR

• Portable MSLT performed in the home setting.


ICD-10 DiagnosisCode ICD-10 Diagnosis Description

F40.241 Acrophobia

F43.0 Acute stress reaction

F43.22 Adjustment disorder with anxiety

F43.21 Adjustment disorder with depressed mood

F43.24 Adjustment disorder with disturbance of conduct

F43.23 Adjustment disorder with mixed anxiety and depressed mood

F43.25 Adjustment disorder with mixed disturbance of emotions and conduct

F43.29 Adjustment disorder with other symptoms

F43.20 Adjustment disorder, unspecified

F51.01 Primary insomnia

F51.02 Adjustment insomnia

F51.03 Paradoxical insomnia

F51.04 Psychophysiologic insomnia

F51.05 Insomnia due to other mental disorder

F51.09 Other insomnia not due to a substance of known physiological condition

F98.5 Adult onset fluency disorder

F40.01 Agoraphobia with panic disorder

F40.02 Agoraphobia without panic disorder

F40.00 Agoraphobia, unspecified

F10.180 Alcohol abuse with alcohol-induced anxiety disorder

F10.14 Alcohol abuse with alcohol-induced mood disorder

F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions

F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations

F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified

F10.181 Alcohol abuse with alcohol-induced sexual dysfunction

F10.182 Alcohol abuse with alcohol-induced sleep disorder

F10.121 Alcohol abuse with intoxication delirium

F10.188 Alcohol abuse with other alcohol-induced disorder

F10.19 Alcohol abuse with unspecified alcohol-induced disorder

F10.280 Alcohol dependence with alcohol-induced anxiety disorder

F10.24 Alcohol dependence with alcohol-induced mood disorder

F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder

F10.27 Alcohol dependence with alcohol-induced persisting dementia

F10.250 Alcohol dependence with alcohol-induced psychotic disorder with delusions

F10.251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations

F10.259 Alcohol dependence with alcohol-induced psychotic disorder, unspecified

F10.281 Alcohol dependence with alcohol-induced sexual dysfunction

F10.282 Alcohol dependence with alcohol-induced sleep disorder

F10.221 Alcohol dependence with intoxication delirium

F10.288 Alcohol dependence with other alcohol-induced disorder

F10.29 Alcohol dependence with unspecified alcohol-induced disorder

F18.951 Inhalant use, unspecified with inhalant-induced psychotic disorder with hallucinations

F18.959 Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified

F18.921 Inhalant use, unspecified with intoxication with delirium

F51.05 Insomnia due to other mental disorder

F51.12 Insufficient sleep syndrome

F63.81 Intermittent explosive disorder

F63.2 Kleptomania

F33.2 Major depressive disorder, recurrent severe without psychotic features

F33.42 Major depressive disorder, recurrent, in full remission

F33.41 Major depressive disorder, recurrent, in partial remission

F33.40 Major depressive disorder, recurrent, in remission, unspecified

F33.0 Major depressive disorder, recurrent, mild

F33.1 Major depressive disorder, recurrent, moderate

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

F33.9 Major depressive disorder, recurrent, unspecified

F32.5 Major depressive disorder, single episode, in full remission

F32.4 Major depressive disorder, single episode, in partial remission

F32.0 Major depressive disorder, single episode, mild

F32.1 Major depressive disorder, single episode, moderate

F32.3 Major depressive disorder, single episode, severe with psychotic features

F32.2 Major depressive disorder, single episode, severe without psychotic features

F32.9 Major depressive disorder, single episode, unspecified

F52.21 Male erectile disorder

F52.32 Male orgasmic disorder

F30.4 Manic episode in full remission

F30.3 Manic episode in partial remission

F30.11 Manic episode without psychotic symptoms, mild

F30.12 Manic episode without psychotic symptoms, moderate

F30.10 Manic episode without psychotic symptoms, unspecified

F30.2 Manic episode, severe with psychotic symptoms

F30.13 Manic episode, severe, without psychotic symptoms

F30.9 Manic episode, unspecified

F42.2 Mixed obsessional thoughts and acts

F06.31 Mood disorder due to known physiological condition with depressive features

F06.32 Mood disorder due to known physiological condition with major depressive-like episode

F06.33 Mood disorder due to known physiological condition with manic features

F06.34 Mood disorder due to known physiological condition with mixed features

F06.30 Mood disorder due to known physiological condition, unspecified

F91.8 Other conduct disorders

F32.8 Other depressive episodes

F80.89 Other developmental disorders of speech and language

F88 Other disorders of psychological development

F50.8 Other eating disorders

F98.29 Other feeding disorders of infancy and early childhood

F64.8 Other gender identity disorders

F45.29 Other hypochondriacal disorders

F63.8 Other impulse disorders

F51.09 Other insomnia not due to a substance or known physiological condition

F42.8 Other obsessive compulsive disorder

F30.8 Other manic episodes

F41.3 Other mixed anxiety disorders

F40.228 Other natural environment type phobia

F65.89 Other paraphilias

F34.8 Other persistent mood Âșaffective» disorders

F07.89 Other personality and behavioral disorders due to known physiological condition

F84.8 Other pervasive developmental disorders

F40.8 Other phobic anxiety disorders

F19.121 Other psychoactive substance abuse with intoxication delirium

F19.122 Other psychoactive substance abuse with intoxication with perceptual disturbances

F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder

F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder

F19.14 Other psychoactive substance abuse with psychoactive substance-induced mood disorder

F19.16 Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder

F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia

F19.150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delus

F19.151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallu

F19.159 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecifi

F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction

F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder

F15.159 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified

F15.181 Other stimulant abuse with stimulant-induced sexual dysfunction

F15.182 Other stimulant abuse with stimulant-induced sleep disorder

F15.19 Other stimulant abuse with unspecified stimulant-induced disorder

F15.221 Other stimulant dependence with intoxication delirium

F15.222 Other stimulant dependence with intoxication with perceptual disturbance

F15.288 Other stimulant dependence with other stimulant-induced disorder

F15.280 Other stimulant dependence with stimulant-induced anxiety disorder

F15.24 Other stimulant dependence with stimulant-induced mood disorder

F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions

F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations

F15.259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified

F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction

F15.282 Other stimulant dependence with stimulant-induced sleep disorder

F15.29 Other stimulant dependence with unspecified stimulant-induced disorder

F15.921 Other stimulant use, unspecified with intoxication delirium

F15.922 Other stimulant use, unspecified with intoxication with perceptual disturbance

F15.988 Other stimulant use, unspecified with other stimulant-induced disorder

F15.980 Other stimulant use, unspecified with stimulant-induced anxiety disorder

F15.94 Other stimulant use, unspecified with stimulant-induced mood disorder

F15.950 Other stimulant use, unspecified with stimulant-induced psychotic disorder with delusions

F15.951 Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations

F15.959 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified

F15.981 Other stimulant use, unspecified with stimulant-induced sexual dysfunction

F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder

F95.8 Other tic disorders

F45.41 Pain disorder exclusively related to psychological factors

F45.42 Pain disorder with related psychological factors

F41.0 Panic disorder Âșepisodic paroxysmal anxiety» without agoraphobia

F51.03 Paradoxical insomnia

F60.0 Paranoid personality disorder

F20.0 Paranoid schizophrenia

F65.9 Paraphilia, unspecified

F63.0 Pathological gambling

F65.4 Pedophilia

F34.9 Persistent mood Âșaffective» disorder, unspecified

F07.0 Personality change due to known physiological condition

F60.9 Personality disorder, unspecified

F84.9 Pervasive developmental disorder, unspecified

F40.9 Phobic anxiety disorder, unspecified

F98.3 Pica of infancy and childhood

F43.11 Post-traumatic stress disorder, acute

F43.12 Post-traumatic stress disorder, chronic

F43.10 Post-traumatic stress disorder, unspecified

F07.81 Postconcussional syndrome

F52.4 Premature ejaculation

F32.81 Premenstrual dysphonic disorder

F51.11 Primary hypersomnia

F51.01 Primary insomnia

F48.2 Pseudobulbar affect

F06.2 Psychotic disorder with delusions due to known physiological condition

F06.0 Psychotic disorder with hallucinations due to known physiological condition

F53 Puerperal psychosis

F63.1 Pyromania

F43.9 Reaction to severe stress, unspecified

F94.1 Reactive attachment disorder of childhood

F20.5 Residual schizophrenia

F98.21 Rumination disorder of infancy

F65.50 Sadomasochism, unspecified

F25.0 Schizoaffective disorder, bipolar type

F25.1 Schizoaffective disorder, depressive type

F25.9 Schizoaffective disorder, unspecified

F60.1 Schizoid personality disorder

F20.9 Schizophrenia, unspecified

F20.81 Schizophreniform disorder

F21 Schizotypal disorder

F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium

F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolyticinduced disorder

F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced anxiety disorde

F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced mood disorder

F13.151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced psychotic disor

Tuesday, November 28, 2017

Cigna denial codes list

Insurance Cigna denial codes list

Code Description Denial Language

1 Services after auth end The services were provided after the authorization was effective and are not covered benefits under this plan.
2 Services prior to auth start The services were provided before the authorization was effective and are not covered benefits under this plan.
3 No auth on file There is no authorization on file for these services.
4 Max Days This claim exceeds the maximum allowed days per benefit period
5 Not member Denied: No coverage effective at time of service.
6 Benefit Day Limit Exceeded. Benefit Day Limit Exceeded.
7 No benefit The patient does not have benefits for this service under this Plan.
8 Not covered The service provided is not a covered benefit under this plan.
9 Before eff date The date you received medical services on the above claim was prior to your effective date of eligibility with this Plan. Please submit your claim to the appropriate Plan.
10 Prior auth required Utilization Management has denied prior authorization for this service.
11 Not a benefit Not a benefit
12 Exceeds annual amount This claim exceeds the annual amount allowed for this benefit.
13 Lifetime max This claim exceeds the lifetime maximum allowed for this benefit.
14 Visit limit This claim exceeds the visit limit allowed for this benefit.
15 Dollar limit This claim exceeds the dollar limit allowed for this benefit.
16 Exceeds auth This services exceeds the number of services authorized.
17 Auth for different provider The authorization on file was issued to a different provider.
18 Experimental Procedure has been determined as being experimental in nature.
19 Mental Health This claim is the responsibility of Bravo Health's Delegated Mental Health Vendor. This claim has been forwarded on your behalf.
20 Not covered This service is not a covered benefit for this plan
21 Capitated This is a capitated service.
22 Hospice Hospice Member - Submit to Original Medicare
23 Capitated This is a capitated service.
24 CompCare Submit all Inpatient Mental Health to Comp Care
26 Vision This claim is the responsibility of Bravo Health's Delegated Vision Vendor. This claim has been forwarded on your behalf.
27 Health and Wellness This claim is the responsibility of Bravo Health's Delegated Health & Wellness Vendor. This claim has been forwarded on your behalf.
28 Dental This claim is the responsibility of Bravo Health's Delegated Dental Vendor. This claim has been forwarded on your behalf.
29 Adjusted claim This is an adjusted claim.
30 Auth match The services billed do not match the services that were authorized on file.
31 Not covered Medicare This service is not covered by Medicare.
32 Not covered benefit This service is not a covered benefit for this plan however the patient is not liable for payment as the Noncoverage provided to the patient did not comply with the program requirements
33 POS Please resubmit this claim with the correct place of service.
35 Per Diem Services included in Per Diem
36 Facility Services included in facility fee
37 RUGS Services included in RUGS rate
38 Visit Services included in visit rate
39 Invalid revenue code Claim has been submitted with an invalid revenue code. Please resubmit a corrected claim.
40 Invalid modifier The modifier submitted on this claim is invalid for the date of service. Please resubmit claim with a valid modifier.
41 Invalid procedure code The procedure code billed is not valid. Please resubmit this claim with a valid code.
42 Invalid ICD9 code Please resubmit this claim with a valid ICD9 diagnosis code.
43 Par filing deadline exceeded All claims for participating providers must be submitted within 180 days of the date of service. This claim was submitted after the filing deadline.
44 No detail Please resubmit this claim with a detailed bill showing the charges and specific services for each date of service. Itemized bills can be faxed to 1(877)-788-2764
45 No EOB Please resubmit with EOB in order to complete processing of the claim.
46 No occurrence code Please resubmit with corrected Occurrence Code on claim
47 Correct occurrence span Please resubmit with corrected Occurrence Code Span on claim.
48 Correct condition code Please resubmit with corrected Condition Code on claim.
49  Duplicate Claim Line (SameMember/DOS/CPT(REV) Duplicate Claim Line (Same Member/DOS/CPT(REV)
50 Duplicate Mem/DOS/Pay To/Rendering Phys/Charges Duplicate Mem/DOS/Pay To/Rendering Phys/Charges
51 Invalid claim data found on IRF claim. Invalid claim data found on IRF claim.
52 Benefit Requires Contracted (PAR) provider. Benefit Requires Contracted (PAR) provider.
53 Benefit requires non-contracted (NONPAR) provider. Benefit requires non-contracted (NONPAR) provider.
54 Service not within the scope of your contract. Service provided is not included within the scope of your contract.
55 Incorrect value code Please resubmit with corrected Value Code on claim
56 Incorrect admission date Please resubmit with corrected Admission Date on claim
57 Discharge status required Discharge status is required for inpatient and SNF claims.
58 Admission source required Admission source required
59 Incorrect patient status Please resubmit with corrected patient status for bill type on claim
61 HIPPS RUGS DOS billed dollars HH PPS and RUGS DOS billed amount should not have a dollar amount.
62 HIPPS RUG requires rehab HIPPS RUG rate code requires rehabilitation therapy
63 Submit EOB Please resubmit with a EOB in order to complete the processing of the claim
64 Duplicate service code Duplicate service code on same claim with no modifier. Please resubmit with corrected modifier on claim.
65 Incorrect From DOS Please resubmit with corrected From DOS on claim.
66 Incorrect To DOS Please resubmit with corrected TO DOS on claim.
67 Incorrect Admit Type Please resubmit with a correct Admit Type on claim.
68 Incorrect HIPPS code Please resubmit with corrected HIPPS code on IRF claim.
69 Incorrect IRF charges Please resubmit with corrected charges on IRF claim
70 Incorrect Rev code/HCPC rate Please resubmit with corrected Revenue Code and HCPCS/Rate on claim
71 Invalid claim line units Claim line units not equal to days reflected with span code 74
72 Annual benefit amount exceeded Annual benefit amount exceeded
73 Lifetime benefit amount exceeded Lifetime benefit amount exceeded
74 Individual Lifetime visits exceeded Individual Lifetime visits exceeded
75 Not covered This service is not a covered benefit under the plan for this date of service.
76 Benefit visit limit exceeded Benefit visit limit exceeded
77 Benefit dollar limit exceeded Benefit dollar limit exceeded
78 Excluded from provider contract This service is excluded from the Provider's contract. Reimbursement will be made only on services covered by the contract.
79 Duplicate Mem/DOS/Service Code/Pay To/Modifier Duplicate Mem/DOS/Service Code/Pay To/Modifier
80 Dup mem/DOS/Svc Code/ Pay To/Rend Phys/Mod Duplicate member/DOS/Service Code/ Pay To/Rendering Physician/Modifier
81 One 0024 revenue code is permitted per claim Per CMS guidelines, only one 0024 revenue code is permitted per claim
82 Resubmit with appropriate diagnosis codes. Please resubmit the claim with appropriate diagnosis codes.
83 Duplicate claim line Duplicate claim line (same provider/member/DOS/CPT(REV)
84 Not covered/Not allowable by contract Service not covered/Not allowable by contract for provider.
85 Duplicate Claim (Provider/Member/DOS) Duplicate Claim (Provider/Member/DOS)
86 No RAP A Request for Anticipated Payment (RAP) has not yet been submitted for this episode. A RAP must be submitted before payment can be made on the final claim of the episode.
87 Unmatched HIPPS The HIPPS code that was submitted on the RAP for this episode does not match the HIPPS code that was billed on the final claim. Please resubmit a corrected claim or RAP.
88 No RAP 2 A Request for Anticipated Payment (RAP) has not yet been submitted for this episode. A RAP must be submitted before payment can be made on the final claim of the episode.
89 Invalid from date The From statement date must equal the date on the service line item. Please submit a corrected claim.
90 The statement From date is a required field. The statement From date is a required field. Please resubmit a corrected claim.
91 Duplicate RAP A Request for Anticipated Payment (RAP) has already been submitted for this episode. A cancellation of the original RAP must be submitted before payment can be made on a corrected RAP.
92 RAP date discrepancy The statement From and Through date on the Request for Anticipated Payment (RAP) should be equal. Please submit a corrected claim.
93 Include rev and HCPC codes for each service. Please resubmit the claim and include both valid revenue and HCPC codes for each service.
94 HIPPS RUGS DOS not in time period. HIPPS RUGS Date of Service is not within the assessment modifier time period.
95 Not a member Denied: No coverage effective at time of service.
96 Need EOB Please resubmit with an Explanation of Benefits from the primary insurance carrier
97 Incorrect bill type Please resubmit this claim with a corrected bill type
98 Incorrect number of units Please resubmit with the correct number of units on claim.
99 Inpatient hospital days have been exhausted. Inpatient hospital days have been exhausted.
100 Rebundled Two or more procedure codes were rebundled into one comprehensive code.
101 Pre-op included Pre-Operative services are included in the surgical package.
102 Post-op included Post-Operative services are included in the surgical package.
103 Medical visit is not separately reimbursable. Medical visit is not separately reimbursable.
104 One initial/3 years Initial visit is only billed once per patient/provider every three years.
105 Duplicate claim. Duplicate claim.
106 Incidental Incidental service(s) to primary procedure do not require separate reimbursement - The patient is not liable for payment.
107 Obsolete or invalid procedure code Obsolete or invalid procedure code
108 Multiple unit or multiple modifier denial. Multiple unit or multiple modifier denial.
109 Unilateral/Bilateral procedure code Unilateral/Bilateral procedure code
110 Mutually exclusive Two or more procedure codes are considered mutually exclusive.
111 Procedure does not require an Assistant Surgeon. Procedure does not require an Assistant Surgeon.
112 Age range discrepancy Provider assigned an age-specific procedure to a patient whose age is outside of the designated age range.
113 Gender discrepancy Provider assigned a gender-specific procedure to a patient of the opposite sex.
114 Invalid diagnosis code Invalid diagnosis code
116 OPPS The services reported on this claim are not separately reimbursable under OPPS.
117 Incorrect blood Line items billing for blood and products is incorrect. Please resubmit a corrected claim.
118 Radiopharm Certain nuclear medicine procedures are performed with specific diagnostic radiopharmaceuticals. The required radiopharmaceutical is not present on the claim. Please resubmit corrected claim.
119 G0739 G0379 must be billed in conjunction with G0378.
120 Inc in Part A The services billed on this claim are considered directly related to an inpatient admission and are not separately billable. These services are included in the Part A payment.
121 Need mod Component of comprehensive procedure that would be allowed if appropriate modifier were present
122 T or S Medical visit on same day as a type T or S procedure without modifier 25.
123 Rev Code Please resubmit with corrected Revenue Code.
124 Mileage Mileage included in base rate.
125 Invoice Submit claim with invoice.
126 Total mismatch Claim total does not match detail line total.
127 Diag required Per CMS regulations this benefit requires specific diagnosis codes.
128 EOB required The primary carrier's explanation of benefits is necessary to consider these services.
129 Single HIPPS Effective January 1, 2008, episodes paid under the refined HH PPS will be paid based on a single HIPPS code. Please submit a corrected claim.
130 Missing Modifier Please resubmit with appropriate or missing modifier.
131 Rendering Provider Rendering Provider Required on Claim
132 POA Please resubmit with a valid POA code
133 SUBMITTED W/O NDC NUMBERS Please resubmit with National Drug Code (NDC) numbers.
134 SUBMITTED W/INVALID NDC #S Please resubmit with a valid National Drug Code (NDC) number. The number submitted is not valid.
135 INVALID NDC NUMBER Please resubmit with a valid National Drug Code (NDC) number. The number submitted is not valid.
136 NDC NUMBER(S) ILLEGIBLE Please resubmit this claim with legible NDC numbers.
137 FIN and NPI mismatch Our data indicates a FIN and NPI mismatch as billed. Please submit a corrected claim.
138 Acute Rehab This is an acute rehab admit. Please resubmit claim with the appropriate case mix group code.
139 OON The benefit for this service is not covered out of network.
140 Add On Add-on billed without primary code.
141 Drug Coverage Only No Medical Coverage. Member has Drug Coverage Only.
142 Bundled Service Bundled Service
143 HIPPS A HIPPS codes is required for this type of claim. Please resubmit with appropriate coding.
144 A8A9 Please resubmit claim with value codes A8 & A9
146 Old Services not billable for the Fiscal Year.
147 OPPS Code not recognized by OPPS; alternate code for the same service may be available.
148 CMS Code not recognized by CMS; alternate code for the same service may be available.
149 Not enrolled Member not enrolled on DOS.
150 Not enrolled group Member was not enrolled with this Medical Group on DOS .
151 Bill on 1500 Resubmit ASC Claims on HCFA ASCs are required to submit claims on form CMS-1500. Please resubmit claim on appropriate form.
152 RUGS Submit with RUGS code.
153 DevCode Claim lacks required device code.
154 Report Code is used for reporting performance measurements only.
155 Invalid G/I- This service code is not valid for Medicare purposes. Medicare uses an alternate code for the reporting and payment of these services. Please resubmit claim with appropriate coding.
156 Excl E- This service code is excluded from the Physician fee schedule by regulation. No payment is made under the MPFS for this code.
157 No RVU J- This code has no Relative Value Unit and no payment amount. The intent of this code is to facilitate the identification of anesthesia services only.
158 APC Reimbursement for this service is included in the APC reimbursement.
159 DRG Payment for this service is included in the DRG rate.
160 Age The diagnosis code includes an age range and the age is outside that range.
161 Gender The diagnosis code includes sex designation and the sex does not match.
162 E Dx The first letter of the principle diagnosis code in an E. This edit is not applicable to the admit diagnosis.
163 Gender Match The sex of the patient does not match the sex designated for the procedure on the record.
164 Bilateral 2x The same bilateral procedure code occurs two or more times on the same service date.
165 Bilateral 2xx The same bilateral procedure code occurs two or more times on the same service date or the same inherent
bilateral procedure code occurs two or more times on the same service date.
166 Mut Excl The procedure is one of a pair of mutually exclusive procedures in the NCCI table coded on the same day, where the use of a modifier is not appropriate.
167 No Mod The procedure is identified as part of another procedure on the claim coded on the same day, where the use of a modifier is not appropriate.
168 No Blood A blood transfusion or exchange is coded but no blood product is coded.
169 Obs A 762 (observation) revenue code is used with a HCPCS other than observation (99217-99220, 99234-99236, G0378, G0379).
170 HCPCS Req Revenue center requires HCPCS.
171 Comp EM Composite E/M conditions not met for observation and line item.
172 Inv Rev Revenue code not recognized by Medicare.
173 No Proc Claim lacks allowed procedure code.
176 Not covered This is not a covered service.
177 Max Maximum out of Pocket has been reached. Eligible Amounts have been paid at 100%.
178 Max copay Maximum copay per diem has been satisfied for this benefit period. No copay per diem applied.
179 Cosurgeon Co-Surgeon Not Covered
180 Credit Credit applied for prior RAP payment
181 MedSurg This service has been down graded to Med/Surg Day
182 Skilled This service has been down graded to Skilled Nursing
183 Subacute This service has been down graded to Subacute
184 Telemetry This service has been down graded to Telemetry
185 Obs 2 This service has been down graded to the Observation Rate
186 Per Diem This service is included in the In-patient Per Diem
187 Obs Rate This service is included in the Observation Rate
188 Package This service is included in the Package Price

189 Stoploss This service is included in the Stop Loss Rate
190 Unequal Itemized Bill not equaled to charges
191 Missing Anes Time Please rebill. The service is billed is missing Anesthesia Time Units
192 Missing CPT MISSING CPT CODE
193 Mult Proc MULTIPLE PROCEDURES BILLED WITHOUT MODIFIER
194 Mult Surg Multiple Surgery Reduction
195 Non Par Timely NON PAR PROVIDER TIMELY FILING
196 Not Quest Lab NON QUEST LAB PROVIDER
197 Convenience Patient convenience items are not covered under this benefit plan.
198 Rebill REBILL USING MEDICARE G CODES
199 Facility Payment Reimbursement for service is included in the payment made to the facility.
200 HH Claims Resubmit HH Claims on UB Home Health Agencies are required to submit claims on form CMS-1450, the UB-04. Please resubmit claim on appropriate form.
201 Self Admin Self administered drugs are not covered services under this plan.
202 SNF Exhaustted SKILLED NURSING DAYS EXHAUSTED
203 3 Units Blood The first three units of blood are not covered services under this plan.
204 UR Denied Days UR DENIED HOSPITAL DAYS
205 After Death This date of service is after the date of the patient's death.
206 DRG Invalid The DRG submitted on this claim is not valid for the fiscal year billed. Please resubmit claim with a corrected DRG.
207 ER in 72 hrs Emergency Room visits within 72 hours of an inpatient admission cannot be billed and reimbursed separately.
208 Inc in case This service is included in the Case Rate
209 Inc in CMG Reimbursement for this service in included in the CMG
210 Denied Days These hospital days have been denied by our Health Services Department.
211 Spec Dx Payment for this benefit requires specific diagnosis codes per CMS guidelines.
212 Dup This is a duplicate of a claim that was previously adjudicated.
213 Location Service Facility Location Required.
214 Adjust for Cap This claim is an adjustment for services capitated incorrectly according to your contract.
215 BT 710 Payment for claims submitted using bill type 710 will be $0.00 as this is a non-payment claim.
216 Excl Excluded Service Not Covered
217 NotMember2 Denied: No coverage effective at time of service.
220 Qual Physician Quality Reporting Indicator codes are for reporting purposes only and are not eligible for reimbursement.

221 Item Bill Itemized Bill Request: Itemized bills can be faxed to 1(877)-788-2764
223 ASC INCLUDED IN ASC RATE
224 CG CLAIMSGUARD ADJUSTMENT
225 Inc Included in other procedure.
226 Dup Duplicate Line on Same Claim
227 IncPay Service included in payment for surgical procedure.
228 NoCov Denied: No coverage effective at time of service.
230 PHP The required Bravo Personal Health Profile Form was not received or was incomplete. Please submit completed/corrected form.
231 Cap This is a capitated service
232 Therapy Please resubmit with the appropriate code to reflect the correct amount of therapies billed.
233 Insuf Svc Insufficient services on a day of a partial hospitalization.
301 Admit Hour Please resubmit with a valid admit hour.
302 Bill Type Please resubmit claim with appropriate bill type for inpatient procedure.
303 Multiple NPI Our data indicates this claim has multiple Rendering NPI Numbers. Please submit a corrected claim.
304 Inpt Proc Inpatient Procedure
305 Dialysis Claim lacking CBSA Dialysis claims require a CBSA. Please resubmit.
306 Invalid CPT for benefit This CPT code is not valid for this benefit. Resubmit claim with Medicare approved code for benefit.
307 RAP received RAP received. Payment for this episode has been paid.
308 Mbr not approved for in home podiatry. This member is not approved to receive podiatry services in the home. No fee-for-service payment will be made.
309 Inpt claim with same DOS as ER Inpatient claim/auth exists for same DOS as ER claim.
310 Code not recognized by OPPS Codes not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x, 13x, 14x). Not paid under OPPS.
311 Operating Physician required Operating Physician Information Required.
312 HomeHealth claim for prev episode not submitted Payment Denied. Previous Episode Final Not Submitted.
313 HIPPS/RUGS charges not equal to $0 HIPPS/RUGS billed charges should equal zero.
314 Invalid RAP Invalid/Incorrect RAP submitted for this episode. Valid/Corrected RAP must be submitted before FINAL can pay
315 Submit TOB 328 to cancel paid final claim Unable to cancel RAP because FINAL has PAID. TOB 328 must be submitted in order to cancel a paid FINAL.
316 Rendering provider name required Individual provider name needed. Please resubmit with corrected information.
317 Max rental period exceeded Based on Medicare pricing guidelines, the rental units have exceeded the maximum rental period of 13 months. The member now owns the equipment.
318 Attending physician NPI missing Attending Physician with identifying NPI is a required field on Home Health claims. Please resubmit with corrected information.
319 TOB 327 for denied claim Unable to process 327 bill type for a previously DENIED claim.
320 Date required for line item BILL WITH SPECIFIC DATES
321 Resubmitted Claim Duplicate of claim in review
322 Invalid date INVALID DATE OF SERVICE
323 Cosurgeon not allowed Co-surgeon not allowed
324 Episode canceled Bill type 328 received; episode and associated claims cancelled.
325 Pay to provider does not match Bravo affiliations The name in box 33 does not match what Bravo has on file. Please resubmit this claim.
326 Group TIN submitted The Tax ID submitted is associated to a Group. Please resubmit this claim with your individual Tax ID.
327 Signature does not match what is on file The signature on the claim does not match the signature Bravo has on file. Please resubmit this claim.
328 Submit to Part D Please submit to your Pharmacy Program.
329 Noncovered OON dental Dental Services Performed by Non-Par Specialists are Not Covered
330 E code cannot be principal DX E code cannot be used as principal diagnosis.
331 Payment for non Medicare covered services Additional payment for services not provided by Medicare.
332 Place of service not covered under OPPS Code indicates a site of service not included in OPPS.
333 Service unit out of range for procedure Service unit out of range for procedure.
334 invalid age Invalid age for service provided
335 invalid sex Invalid sex
336 Mental Health dx required Partial hospitalization service for non-mental health diagnosis.
337 Only therapy services provided Only activity therapy and/or occupational therapy services provided.
338 Invalid units for bilateral procedure Terminated bilateral procedure or terminated procedure with units greater than one.
339 Implanted dev code & administered sub do not match Inconsistency between the implanted device or the administered substance and the implantation or associated procedure.
340 Inpt procedures not payable Inpatient separate procedures not paid.
341 Multiple codes for same service Multiple codes for same service.
342 Invalid dx for clinical trial Clinical trial requires diagnosis codes V707 as other than primary diagnosis.
343 Modifier CA billed for multiple procedures Use of modifier CA with more than one procedure not allowed.
344 Invalid service for OT code This OT code only billed on partial hospitalization claims.
345 Invalid service for AT code AT service not payable outside the partial hospitalization program.
346 Service not FDA approved Service provided prior to FDA approval.
347 Service not approved by NCD Service provided prior to date of National Coverage Determination (NCD) approval.
348 Service provided outside approval period Service provided outside approval period.
349 Invalid pt status for CA modifier CA modifier requires patient status code 20.
350 Billed amt cannot exceed $1.01) Charge exceeds token charge ($1.01).
351 Invalid condition code for bill type Partial hospitalization condition code 41 not approved for type of bill.
352 Claim does not meet obs criteria Observation does not meet minimum hours, qualifying diagnoses, and/or 'T' procedure conditions.
353 Invalid bill type for observation Observation G codes only allowed with bill type 13x.
354 Non-reportable for site of service Non-reportable for site of service.
355 E/M conditions not met for observation criteria E/M conditions not met and line item date of obs code G0244 is not 12/31 or 01/01.
357 Incorrect billing of modifier FB or FC. Incorrect billing of modifier FB or FC.
358 Invalid code for place of service Mental health code not approved for partial hospitalization.
359 Invalid code for place of service Mental health service not payable outside the partial hospitalization program.
360 Service provided outside approval
period Service provided on or after effective date of NCD non-coverage.
361 Not a covered Medicaid benefit The patient does not have benefits for this service under this Medicaid Plan.
365 Medical documentation required Please resubmit claim with the appropriate medical documentation.
369 No OON Medicaid coverage for this benefit The benefit for this service is not covered out of network service for this Medicaid Plan.
370 Code billed in excess of once per 90 period Report only once every 90 days per CPT.
371 TOB 328 received with no matching claim in history
328 Received. No matching claim found for cancellation request. Cancellation request must match claim on file.
372 Invalid admin code Resubmit with appropriate administration code.
373 Submit to ASH This claim is the responsibility of Bravo Health's Delegated Chiropractor Vendor. This claim has been forwarded on your behalf.
374 Service paid previously to another provider. Payment Denied. Information on file indicates services are provided by another provider.
375 Incorrect Admission Source Please submit with correct Admission Source.
376 CMS Noncovered ICD9/CPT Mods billed This claim has been denied for payment since it contains one or more of the ICD-9 codes or CPT modifiers CMS
has identified as not eligible for payment.
377 Resubmit proc code Please resubmit with a specific procedure code.
378 Resubmit claim form Please resubmit claim on the correct claim form type.
379 Invalid ASC Code The service billed is not an approved ASC procedure.
380 Invalid Date Span The "from" and "to" dates must be different.
381 IB fax number Please fax bills to 1(877)-788-2764.
382 Invalid DRG No DRG found for the codes used.
383 Invalid secondary diagnosis Invalid secondary diagnosis code.
384 Invalid discharge date Invalid discharge date.
385 Global day overlap Not reimbursable. Services rendered are within the global day billing period.
386 HHDisenroll This member disenrolled during the home health episode. A claim for a partial episode payment must be submitted in order for charges to be adjudicated properly.
387 BPHP previously paid The Bravo Personal Health Profile has already been reimbursed for this member for the current calendar year.
388 Claim cancelled Bill Type 118 received and claim was cancelled.
389 Leave of Absence and Level of Care mismatch Leave of Absence and Level of Care cannot be billed with same Date of Service 390 Service cannot be billed on same date as LOC Code cannot be billed without Level of Care on same Date of Service
393 Invalid Discharge Status Invalid Discharge Status
998 Negative Check This amount has been credited to a prior adjustment.
999 Reversed Claim This claim represents an adjustment to claim ___ processed on mm/dd/yyyy.
1001 MUE Edit The units of service billed exceeds our acceptable maximum units (MUE-medically unlikely edits)
1002 Incorrect TOB ESRD Hospitals with a Medicare certified renal dialysis facility should have outpatient ESRD related services billed by the hospital-based renal dialysis facility on bill type 72x.
1003 EOP Required Please resubmit with a copy of the Explanation of Payment from the primary carrier.
1004 MSP This claim has been paid in full by the primary carrier.
1005 HH Treatment Code not billed 18 digit Alpha/Numeric MCR Treatment Authorization code not present on claim. Please resubmit claim.
1006 Resubmit with RUGs code Resubmit claim with valid RUGS code.
1007 Multiple rev code 0023 Multiple instances of revenue code 0023 billed on a single claim.
1008 Missing or invalid Admit Date Admit date is missing or invalid.
1009 Negative charges not allowed Negative charges are not permitted on a claim service line
1011 Team surgeon not allowed Team surgeon not allowed.
1012 HCPCS required Surgical procedure requires HCPCS.
1013 Benefit not separately reimbursed This benefit is not separately reimbursed.
1014 Member not within age range for benefit The benefit for the service rendered is not within the age range for the member.
1015 Only one anesthesia code per surgical session Only one primary anesthesia should be reported for a surgical session.
1017 Service Not Covered Service Not Covered
1018 Missing EMS report Need ambulance EMS report.
1019 Invalid anesthesia code Need valid anesthesia code.
1020 Admit date under previous contract Service dates not matching proper 60 Day Episodic span from Start of Care, Admit date under previous contract. Services reimbursed under previous contract due to Admit date
1021 Missing form A single case agreement referral form must accompany each claim submitted.
1023 Missing OP report Resubmit with OP report.
1024 Invalid discharge hour Invalid Discharge Hour
1025 ERAP payment Payment denied. Information on file indicates payment was made to another provider.
1026 Units billed exceeds auth The number of units billed exceeds the number of units authorized.
1027 Refund received due to billing error Refund received due to billing error
1028 Refund Received resubmit to LifeSynch Refund Received resubmit to LifeSynch
1029 Raytel and service location not in
box 33 Please resubmit using Raytel's Tax ID and the service location along with Raytel's name in box #33.
1030 Invalid primary or admitting dx code Invalid primary or admitting diagnosis code – please resubmit with appropriate Dx code
1031 Primary dx paired with secondary dx Primary Dx is not acceptable unless paired with appropriate secondary Dx
1032 Billable visit not appropriate level First billable visit not skilled at appropriate level
1033 Supply revcodes not on claim Provider billed HHPPS FINAL indicating Medical/Surgical supplies. Supply Revenue Code 027x and/or 062x not present on claim. Please resubmit corrected claim
1034 Revcode requires HCPCS, DOS and amount Revenue code 0274 requires an HCPCS code, the date of service units and a charge amount
1035 Cancellation submitted prior to up/downcoding

In order to bill new HHPPS HHRG code, a 328 cancellation needs to be submitted to cancel current HHPPS HHRG code on file before new up coded or down coded HHRG/HHPPS code can be billed.
1036 Unable to adjust RAPS Unable to adjust RAPS. RAPS must be canceled and re-billed in order to correct information on file.
1037 No claim in std benefit period No claim in std benefit period before use of reserve days
1038 Other agency responsible for payment Other agency may be responsible for payment
1040 Timely filing This claim was submitted after the filing deadline.
1046 Invalid specialty for svc Provider specialty invalid for service rendered.
1049 Resubmit to TX Mcaid , MCO not responsible for InP Submit Inpatient Acute Care Claims to TMHP.
1050 MOOP This member has reached the max out-of-pocket amount for 2011. If cost-share in excess of what is shown on the EOP has been collected, please reimburse the difference to the member.
1051 Medicare not reimbursing procedure code This procedure code is not reimbursable through Medicare. Please resubmit with a valid code.
1052 Not medically necessary Medical necessity not established for services rendered.
1053 Attendant Care Payment Based upon Participation Level, Attendant Care Enhanced Payment is included in claim payment.
1054 Resubmit with CMS rate sheet Resubmit claim with a CMS rate sheet.
1055 Cancellation recd, claim cancelled. The cancellation claim was received; claim was cancelled.
1056 327 recd; adjustment adjudicated TOB 327 received; adjustment adjudicated.
1057 Billed service to DMERC Service can only be billed to the DMERC.
1058 Denied for wrong surgery Claim detail denied due to wrong surgery performed on client
1059 Pending Rate Hearing State has not issued procedure code pricing. Claims will be reprocessed when State issues rates.
1060 ICRS DRG audit Claim reversal is due to ICRS DRG audit.
1061 Resubmit with a DRG Please resubmit your claim with a DRG.
1062 Code is Included Services included per CPT Guidelines.
1064 CODE CHANGED PROCEDURE CODE CHANGED PER REVIEW
1065 INCLUDED IN PRIMARY PROCEDURE INCLUDED IN PRIMARY PROCEDURE
1066 PROCEDURE INAPPROPRIATELY CODED PROCEDURE INAPPROPRIATELY CODED
1067 NOT A COVERED SERVICE NOT A COVERED SERVICE
1068 NOT A COVERED SERVICE FOR PROVIDER SPECIALTY NOT A COVERED SERVICE FOR PROVIDER SPECIALTY

Tuesday, November 21, 2017

BCBS denial code list

Reason codes, and the text messages that define those codes, are used to explain why a claim may not have been paid in full. For instance, there are reason codes to indicate that a particular service is never covered by Medicare, that a benefit maximum has been reached, that non-payable charges exceed the fee schedule, or that a psychiatric reduction has been made. Under the standard format, only reason codes approved by the American National Standards Institute (ANSI) Insurance Subcommittee and Medicare-specific supplemental messages approved by CMS may be used.

The ANSI reason codes were designed to replace the large number of different codes used by health payers in this country, and to relieve the burden of medical providers to interpret each of the different coding systems. Although reason codes and CMS message codes will appear in the body of the remittance notice, the text of each code that is used will be printed at the end of the notice to facilitate interpretation. The approximately 10,000 different messages used by Medicare carriers nationwide have been reduced to fewer than 400 messages. The standard messages may expand or change occasionally as the need arises, but CMS plans to limit the frequency of such changes.

Code Description

01 Deductible amount.
02 Coinsurance amount.
03 Co-payment amount.
04 The procedure code is inconsistent with the modifier used, or a required modifier is missing.
05 The procedure code/bill type is inconsistent with the place of service.
06 The procedure/revenue code is inconsistent with the patient’s age.
07 The procedure/revenue code is inconsistent with the patient's gender.
08 The procedure code is inconsistent with the provider type/specialty (taxonomy).
09 The diagnosis is inconsistent with the patient's age.
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.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using remittance advice remarks codes whenever appropriate.
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
23 Payment adjusted because charges have been paid by another payer.
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25 Payment denied. Your stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Benefit maximum has been reached.
36 Balance does not exceed co-payment amount.
37 Balance does not exceed deductible.
38 Services not provided or authorized by designated (network) providers.
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract.
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/legislated fee arrangement.
46 This (these) service(s) is (are) not covered.
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
48 This (these) procedure(s) is (are) not covered.
49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
50 These are non-covered services because this is not deemed a "medical necessity" by the payer.
51 These are non-covered services because this is a pre-existing condition.
52 The referring/prescribing provider is not eligible to refer/prescribe/order/perform the service billed.
53 Services by an immediate relative or a member of the same household are not covered.
54 Multiple physicians/assistants are not covered in this case.
55 Claim/service denied because procedure/ treatment is deemed experimental/ investigational by the payer.
56 Claim/service denied because procedure/ treatment has been deemed “proven to be effective” by the payer.
57 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.
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59 Charges are reduced based on multiple surgery rules or concurrent anesthesia rules.
60 Charges for outpatient services with this proximity to inpatient services are not covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
62 Payment denied/reduced for absence of, or exceeded, precertification/ authorization.
63 Correction to a prior claim.
64 Denial reversed per Medical Review.
65 Procedure code was incorrect. This payment reflects the correct code.
66 Blood deductible.
67 Lifetime reserve days.
68 DRG weight.
69 Day outlier amount.
70 Cost outlier. Adjustment to compensate for additional costs.
71 Primary payer amount.
72 Coinsurance day.
73 Administrative days.
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days.
78 Non-covered days/Room charge adjustment.
79 Cost report days.
80 Outlier days.
81 Discharges.
82 PIP days.
83 Total visits.
84 Capital Adjustment.
85 Interest amount.
86 Statutory Adjustment.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim paid in full.
93 No claim level adjustments.
94 Processed in excess of charges.
95 Benefits adjusted. Plan procedures not followed.
96 Non-covered charges.
97 Payment is included in the allowance for another service/procedure.
98 The hospital must file the Medicare claim for this inpatient non-physician service.
99 Medicare Secondary Payer Adjustment amount.
100 Payment made to patient/insured/responsible party.
101 Predetermination. Anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount).
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not paid or identified on the claim.
108 Payment adjusted because rent/purchase guidelines were not met.
109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
113 Payment denied because service/procedure was provided outside the United
States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or cancelled.
116 Payment denied. The advance indemnification notice signed by the patient
did not comply with requirements.
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period has been reached.
120 Patient is covered by a managed care plan.
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment.
124 Payer refund amount – not our patient.
125 Payment adjusted due to a submission/billing error(s). Additional information
is supplied using the remittance advice remarks codes whenever appropriate.
126 Deductible – Major Medical.
127 Coinsurance – Major Medical.
128 Newborn’s services are covered in the mother’s allowance.
129 Payment denied. Prior processing information appears incorrect.
130 Claim submission fee.
131 Claim specific negotiated discount.
132 Prearranged demonstration project adjustment.
133 The disposition of this claim/service is pending further review.
134 Technical fees removed from charges.
135 Claim denied. Interim bills cannot be processed.
136 Claim adjusted. Plan procedures of a prior payer were not followed.
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138 Claim/Service denied. Appeal procedures not followed or time limits not met.
139 Contracted funding agreement. Subscriber is employed by the provider of the services.
140 Patient/Insured health identification number and name do not match.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 Claim adjusted by the monthly Medicaid patient liability amount.
143 Portion of payment deferred.
144 Incentive adjustment, e.g., preferred product/service.
145 Premium payment withholding.
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
147 Provider contracted/negotiated rate expired or not on file.
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
A0 Patient refund amount.
A1 Claim denied charges.
A2 Contractual adjustment.
A3 Medicare Secondary Payer liability met.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
A7 Presumptive Payment Adjustment.
A8 Claim denied; ungroupable DRG.
B1 Non-covered visits.
B2 Covered visits.
B3 Covered charges.
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
B6 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.
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8 Claim/service not covered/reduced because alternative services were available, and should not have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
B12 Services not documented in patient’s medical records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14 Payment denied because only one visit or consultation per physician per day is covered.
B15 Payment adjusted because this service/procedure is not paid separately.
B16 Payment adjusted because "new patient" qualifications were not met.
B17 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. B18 Payment denied because this procedure code/modifier was invalid on the
date of service or claim submission.
B19 Claim/service adjusted because of the finding of a Review Organization.
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
B21 The charges were reduced because the service/care was partially furnished by another physician.
B22 This payment is adjusted based on the diagnosis.
B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
D1 Claim/service denied. Level of subluxation is missing or inadequate.
D2 Claim lacks the name, strength, or dosage of the drug furnished.
D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
D4 Claim/service does not indicate the period of time for which this will be needed.
D5 Claim/service denied. Claim lacks individual lab codes included in the test.
D6 Claim/service denied. Claim did not include patient's medical record for the service.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.
D8 Claim/service denied. Claim lacks indicator that "x-ray is available for review”.
D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
D10 Claim/service denied. Completed physician financial relationship form not on file.
D11 Claim lacks completed pacemaker registration form.
D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
D14 Claim lacks indication that plan of treatment is on file.
D15 Claim lacks indication that service was supervised or evaluated by a physician. W1 Workers Compensation State Fee Schedule Adjustment.

Wednesday, November 15, 2017

Nebulizer cpt code list - A7017, A7018, A7007

For a DME item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Nebulizers require an in-person or face-to-face interaction between the beneficiary and their treating physician prior to prescribing the item, specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. A dispensing order is not sufficient to provide these items. A WOPD (written order prior to delivery) is required.

Detailed documentation requirements are outlined in Nebulizer LCD

HCPCS Code Description

A4217 Sterile water/saline, 500 ml
A4218 Sterile saline or water, metered dose dispenser, 10 ml
A4619 Face tent
A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
A7004 Small volume nonfiltered pneumatic nebulizer, disposable
A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
A7006 Administration set, with small volume filtered pneumatic nebulizer
A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor
A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor (noncovered per LCD) A7009 Reservoir bottle, non-disposable, used w/ large volume ultrasonic nebulizer (noncovered per LCD)
A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet
A7011 Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet
A7012 Water collection device, used with large volume nebulizer
A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator
A7014 Filter, nondisposable, used with aerosol compressor or ultrasonic generator
A7015 Aerosol mask, used with DME nebulizer
A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen
A7018 Water, distilled, used with large volume nebulizer, 1000 ml
A7525 Tracheostomy mask, each
G0333 Pharmacy dispensing fee for inhalation drug(s); initial 30-day supply as a beneficiary
J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 300 mg
J7604* Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram
J7605 Arformoterol, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 15 micrograms
J7606 Formoterol fumarate, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose form, 20 micrograms
J7607* Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg
J7608 Acetylcysteine, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per gram
J7609* Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg
J7610* Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg
J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg
J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg
J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg
J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg
J7615* Levalbuterol, inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg


QUESTIONS AND ANSWERS

Q: Is a large volume ultrasonic nebulizer (HCPCS E0575) covered by Medicare?

A: A large volume ultrasonic nebulizer offers no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not reasonable and necessary.


Q: Are compound inhalation solutions covered by Medicare?

A: CMS revoked coverage of compounded inhalation solutions in 2007.


Q: Are there any restrictions around nebulizers and home oxygen use?

A large volume pneumatic nebulizer (HCPCS E0580) and water or saline (HCPCS A4217 or A7018) are not separately payable and should not be separately billed when used for beneficiaries with rented home oxygen equipment.


Medical Records

If the claim includes a nebulizer with compressor (E0570), the medical records include a face-to-face examination by the treating physician that meets the following requirements: The examination occurred within 6 months prior to the date of the written order that was obtained prior to delivery; and

The examination documents that the beneficiary was evaluated and/or treated for a condition that supports the need for a nebulizer with compressor in order to administer inhalation drugs.

A date stamp or similar indicator verifies that the supplier received a copy of the F2F note on or before the date of delivery.

Continued Medical Need for the Equipment/Accessories/Supplies is Verified by Either:

A refill order from the treating physician dated within 12 months of the date of service under review; or

A change in prescription dated within 12 months of the date of service under review; or

A medical record, dated within 12 months of the date of service under review, that shows usage of the item. Claims for a Small Volume Ultrasonic Nebulizer (E0574)

A small volume ultrasonic nebulizer is reasonable and necessary to administer treprostinil inhalation solution only (See Treprostinil/Iloprost Inhalation Solution Checklist). Claims for code E0574 used with other inhalation solutions will be denied as not reasonable and necessary. Claims for HCPCS Code E1399 (Miscellaneous Equipment or Accessories)

The claim includes a clear description of the item including:

The manufacturer’s name,

The model name/number,Pricing information, and An explanation of medical necessity. Claims for HCPCS Code J7699 (NOC Nebulizer Drug Code)

The claim is accompanied by:

Detailed order information as described in the written order requirements,

A clear statement of the number of ampules/bottles of solution dispensed, and Documentation of the medical necessity of the drug for that beneficiary.

It is expected that the beneficiary’s medical records will reflect the need for the care provided. These records are not routinely submitted to the DME MAC but must be available upon request. Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review the appropriate medical records and maintain a copy in the beneficiary’s file.

Additionally, while the nebulizer drug LCD does not require suppliers who only provide the nebulizer to keep a file copy of the written order for the drug(s), it is strongly recommended that the supplier do so. In the event of a claim audit by the DME MAC, CERT, or ZPIC contractor, documentation the supplier will be required to submit in order to verify the medical necessity for the nebulizer will include a copy of the detailed written order for the drug(s). Failure to provide the written order in a timely manner could result in denial of the nebulizer claim and an overpayment assessment.

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