Tuesday, June 1, 2010

CO 16, N 290, N 257, CO 5 AND - Denial reason codes

Medicare Denial reason code co 16


Q: We received a returned unprocessable claim (RUC) with claim adjustment reason code (CARC) CO 16. What steps can we take to avoid this RUC code?

CO 16: Claim/service lacks information or has submission/billing error(s) which is/are needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCDPD Reject Reason Code or Remittance Advice Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

A: CARC CO 16 applies to various scenarios regarding missing or invalid information on the claim. To avoid delay in payment, submit a corrected claim. Claims that are returned as unprocessable cannot be appealed, as an initial determination was not made.

Please review the remittance advice remark codes (RARCs) pertaining to your claim and then check on the applicable topic below for steps you can take to avoid the RUC:

Beneficiary name and/or Medicare number

MA61: Missing/incomplete/invalid Social Security number or health insurance claim number (HICN).
MA36: Missing /incomplete/invalid patient name.
MA27: Missing/incomplete/invalid entitlement number or name shown on the claim.
• Review and make a copy of patient’s Medicare card for file and verify eligibility. 
• Enter patient’s name on claim as indicated on Medicare card.
• Include spaces and special characters if indicated on Medicare card. Exception: PC-ACE software currently does not accept special characters; enter space instead.
• Enter patient’s HICN exactly as indicated on Medicare card.



Billing entity/provider

N256: Missing/incomplete/invalid billing provider/supplier name.
N257: Missing/incomplete/invalid billing provider/supplier primary identifier.
N258: Missing/incomplete/invalid billing provider/supplier address.
MA112: Missing/incomplete/invalid group practice information.

• Refer to Item(s) 33 and/or 33A on the claim form. These are required fields. Enter the billing provider/supplier name, address and zip code in Item 33, and the billing provider’s, or group’s, NPI in Item 33A.




Charges on claim

M79: Missing/incomplete/invalid charge.
• Refer to Item 24F on the claim form. Medicare does not pay for services when a charge is not indicated. Enter a charge for each service listed on the claim..



CLIA certification number

MA120: Missing/incomplete/invalid CLIA certification number.
• Refer to Item 23 on the claim form. Enter the ten-digit CLIA certification number for laboratory services billed.

Date range not valid with units submitted

M52: Missing/incomplete/invalid –from- date(s) of service.
N345: Date range not valid with units submitted.
• Refer to Item(s) 24A and/or 24G on the claim form. Ensure date(s) of service (DOS) correspond(s) to the number of units/days billed. If billing for more than one unit on a single day, services may need to be itemized, one per line.
Facility ZIP code or state code

N104: This claim service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Categorization_of_Tests.html external link.
• Refer to Item 32 on the claim form. Service facility information is used to price claims. Enter the state code and ZIP code on the claim.
• Click here external link to see if a 9-digit ZIP code is needed for the facility.
• The state code should be referred to as the province code for providers in U.S. Virgin Islands.

Facility/laboratory name and/or address

N294: Missing/incomplete/invalid service facility primary address.
MA114: Missing/incomplete/invalid information on where the services were furnished.
• Refer to Item 32 on the claim form. Service facility information is used to price claims. Enter the service location name and complete address on the claim.
• Enter the service location name, street address, city, state and a valid ZIP code in item 32.
• The location where the service was rendered is required for all place of service (POS) codes.
• If additional entries are needed, separate claim forms must be submitted.
• If required by Medicare claims processing policy, enter the NPI of the service facility in item 32a.
Purchased service/primary provider identifier

N270: Missing/incomplete/invalid other provider primary identifier.
N283: Missing/incomplete/invalid purchased service provider identifier.
Effective for claims submitted with a receipt date on and after October 1, 2015, billing physicians and suppliers must report the name, address, and NPI of the performing physician or supplier on all anti-markup and reference laboratory claims, even if the performing physician or supplier is enrolled in a different contractor’s jurisdiction. Physicians and suppliers may no longer indicate their own information when the laboratory service(s) were purchased..
• Enter the valid performing physician or supplier’s NPI in item 32a.
• Enter the actual performing physician/supplier’s name, address and ZIP code in item 32.

Note: Do not combine non-referred (i.e., self-performed) and referred services on the same CMS 1500 claim form. Submit two separate claims, one claim for non-referred tests and the other for referred tests.
ICD diagnosis codes

M76: Missing/incomplete/invalid diagnosis or condition.
M81: You are required to code to the highest level of specificity
• Refer to Item 21 on the claim form. Enter the ICD Indicator and diagnosis code on the claim.
• Enter the appropriate ICD Indicator as a single digit between the vertical, dotted lines.
• Indicator ‘9’ is used for ICD-9-CM diagnosis codes.
• Indicator ‘0’ is used for ICD-10-CM diagnosis codes.
• Enter up to 12 diagnosis codes, in priority order. The diagnosis codes must be coded to the highest level of specificity.
• Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service.
• Do not insert a period in the ICD-9-CM or ICD-10-CM codes.
Example: Diagnosis code 285.21 is entered as 28521, without a period or space.
• Reminder: Do not report ICD-10-CM codes for claims with date(s) of service prior to October 1, 2015.
Incorrect claim form/format
N34: Incorrect claim form/format for this service.
• Refer to Items 11b, 12, 14, 16, 18, 19, 24a and 31 on the claim form. You have the option to enter either a 6-digit (MMDDYY) or 8-digit (MMDDCCYY) date. However, the date format you choose must be consistent throughout the claim.
• e.g., if you choose the 6-digit format for the first date field, then that 6-digit format must be used in all subsequent date fields in the provider portion of that particular claim. Conversely, if you use the 8-digit format for the first date field, then you would continue to use the 8-digit format for the remainder of the date fields in the provider portion of that particular claim.
Ordering or referring physician name, qualifier and/or NPI

N264: Missing/incomplete/invalid ordering provider name.
N265: Missing/incomplete/invalid ordering provider primary identifier.
N276: Missing/incomplete/invalid other payer referring provider identifier.
N285: Missing/incomplete/invalid referring provider name.
N286: Missing/incomplete/invalid referring provider primary identifier.
• Refer to Items 17 and 17B on the claim form. Enter the name and qualifier in Item 17, and the NPI in Item 17B.
Physician/supplier signature

MA81: Missing/incomplete/invalid provider/supplier signature.
• Refer to Item 31 on the claim form. The signature of the physician or non-physician practitioner is required. The following formats are acceptable.
• Actual signature
• “Signature on file” notation (if applicable)
• Computer-generated signature
Primary or secondary payer information

MA83: Did not indicate whether Medicare is the primary or secondary payer.
• Refer to Item 11 on the claim form. This is a required field. By completing this item, a physician/supplier acknowledges that he/she made a good faith effort to determine whether Medicare is the primary or secondary payer.
• If Medicare is primary, enter the word “NONE.”
• If Medicare is secondary, enter the insured’s policy or group number, and precede with Items 11a -11c.
• Note: Items 4, 6 and 7 must also be completed.
Procedure codes

M51: Missing/incomplete/invalid procedure code(s).
• Refer to Item 24D on the claim form. Before submitting your claim, ensure you use the most current year's Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes and/or Physician Quality Reports System (PQRS) measure codes.
• Check Medicare status code via our fee schedule lookup tool  to confirm the procedure code is valid for Medicare. Be aware that status codes may change, so a procedure code that was previously valid for Medicare or for PQRS reporting may no longer be valid.
• If the procedure code has an “I” status, the procedure code is not valid for Medicare or for PQRS reporting.
• Valid procedure codes for PQRS reporting indicate an “M” (measurement codes) status. Providers billing “I” status procedure codes will not get PQRS reporting credit which may result in payment adjustments. For additional information, click here to go to our PQRS page.
• Click here for additional information regarding procedure codes.
Rendering physician NPI

N290: Missing/incomplete/invalid rendering provider primary identifier.
MA112: Missing/incomplete/invalid group practice information.
• Refer to Item 24J on the claim form. If the rendering provider is linked to the group, enter the individual practitioner’s NPI in the unshaded portion of this field.

Denial Message

• Claim/service lacks information which is needed for adjudication (16)
• Missing/incomplete/invalid rendering provider identifier (290)

Reason for denial

• The claim was filed with an invalid or missing rendering NPI

How to resolve and avoid future denials

• Refile the claim with the valid rendering provider’s NPI in Item 24J of the CMS 1500 claim form

• For assistance with obtaining NPIs
o NPI Registry
• https://nppes.cms.hhs.gov

Denial message co 16 N257



• Claim/service lacks information which is needed for adjudication (16)
• Missing/incomplete/invalid billing provider primary identifier (257)

Reason for denial

• The claim was filed with an invalid or missing NPI

How to resolve and avoid future denials

• File claims with the valid billing provider NPI
• Verify the appropriate billing provider NPI is listed in Item 33 of CMS 1500 claim form
• Billing for group – use group NPI
• Solo practitioner – use individual NPI

Denial message code CO 5



• The procedure code/bill is inconsistent with the place of service (05)

Reason for the denial

• Service was rendered at a facility/location that was inappropriate or invalid

How to resolve and avoid future denials

• Verify that the procedure code/bill is consistent with the place of service
• Resubmit as a new claim with a procedure code consistent with the place of service

Most common denial reason along with Denial code CO 16


0391 MEDICARE DEDUCTIBLE AMOUNT MISSING-DETAIL
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.

N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT
0392 MEDICARE PAID AMOUNT NOT NUMERIC-DETAIL

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT

0393 MEDICARE DEDUCTIBLE AMOUNT MISSING
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.

N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT

0394 MEDICARE CO-INSURANCE AMOUNT MISSING

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT

0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.

M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE
0396 HEADER STATEMENT COVERS PERIOD "FROM" DATE INVALID
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.

M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE
0397 HEADER STMT COVERS PERIOD "THROUGH" DATE MISSING
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.


M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE
0398 STATEMENT COVERS PERIOD "THROUGH" DATE INVALID

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE

0400 DETAIL UNITS OF SERVICE MUST BE GREATER THAN ZERO
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.

M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE.
0401 PRESENT ON ADMISSION INDICATOR MISSING

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N434 MISSING/INCOMPLETE/INVALID PRESENT ON ADMISSION INDICATOR.
0402 PRESENT ON ADMISSION INDICATOR INVALID

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N434 MISSING/INCOMPLETE/INVALID PRESENT ON ADMISSION INDICATOR.
0403 PRESENT ON ADMISSION IND PRESENT WHERE NOT ALLOWED

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N434 MISSING/INCOMPLETE/INVALID PRESENT ON ADMISSION INDICATOR.
0405 PAID PAPE WITH 0 ALLOWED UNITS B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT.
- -
0410 MEDICARE DENIAL ON CROSSOVER CLAIM
16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.

N8 CROSSOVER CLAIM DENIED BY PREVIOUS PAYER AND COMPLETE CLAIM DATA NOT FORWARDED. RESUBMIT THIS CLAIM TO THIS PAYER TO PROVIDE ADEQUATE DATA FOR ADJUDICATION.
0427 ACCIDENT DATE INVALID 16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N305 MISSING/INCOMPLETE/INVALID INJURY/ACCIDENT DATE.
0431 DEDUCTIBLE AMOUNT INVALIDDETAIL

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT
0432 COINSURANCE AMOUNT INVALIDDETAIL

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT
0433 MEDICARE DEDUCTIBLE AMOUNT INVALID

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT
0434 MEDICARE COINSURANCE AMOUNT INVALID

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT
0436 TOTAL MEDICARE ALLOWED AMOUNT INVALID

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE
0437 MEDICARE PSYCH ADJUSTMENT AMOUNT INVALID

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
M49 MISSING/INCOMPLETE/INVALID VALUE CODE(S) OR AMOUNT(S).
0438 TOTAL MEDICARE ALLOWED AMOUNT INVALID-DETAIL

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE
0439 PSYCH ADJUSTMENT (PR122) AMOUNT INVALID-DETAIL

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT
0440 MCARE PAID 100% OF CLAIMHEADER
169 ALTERNATE BENEFIT HAS BEEN PROVIDED. - -
0441 MCARE PAID 100% OF CLAIM-DETAIL 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. - -
0442 MEDICARE PAID AMOUNT NOT NUMERIC-HEADER

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
MA04 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY OF OR PAYMENT INFORMATION FROM THE PRIMARY PAYER. THE INFORMATION WAS EITHER NOT REPORTED OR WAS ILLEGIBLE
0443 MEDICARE PAID AMOUNT NOT NUMERIC-DETAIL

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION. MA04 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY OF OR PAYMENT INFORMATION FROM THE PRIMARY PAYER. THE INFORMATION WAS EITHER NOT REPORTED OR WAS ILLEGIBLE
0444 MEDICARE APPROVED AMOUNT = 0 - HEADER
169 ALTERNATE BENEFIT HAS BEEN PROVIDED. - -
0445 MEDICARE APPROVED AMOUNT = 0 - DETAIL
169 ALTERNATE BENEFIT HAS BEEN PROVIDED. - -
0450 INVALID QUADRANT 16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
N346 MISSING/INCOMPLETE/INVALID ORAL CAVITY DESIGNATION CODE.
0452 DTL RENDERING/PERFORMING PROVIDER SERV LOC MISSING

16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE.

2 comments:

  1. A claim denied as N522 code and no explanaton of what this code represents.
    can you Help identify?

    ReplyDelete
    Replies
    1. Duplicate of a claim processed, or to be processed, as a crossover claim.

      Delete

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