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MIR-2007-3AB, March 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update
Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare contractors (carriers, fiscal intermediaries (FI), regional home health intermediaries (RHHI), Part A/B Medicare Administrative Contractors (A/B MAC), durable medical equipment regional carriers (DMERC) and DME Medicare Administrative Contractors (DME MAC)) for services
Provider Action Needed
CR 5456, from which this article is taken, announces the latest update of X12N 835 Health Care Remittance Advice Remark Codes and X12N 835 and 837 Health Care Claim Adjustment Reason Codes, effective April 2, 2007. Be sure billing staff are aware of these changes.
Background
Two code sets—the reason and remark code sets—must be used to report payment adjustments in remittance advice transactions. The reason codes are also used in some coordination-of-benefits (COB) transactions. The RARC list is maintained by the Centers for Medicare & Medicaid Service (CMS), and used by all payers; and additions, deactivations, and modifications to it may be initiated by both Medicare and non-Medicare entities. The health care claim adjustment reason code list is maintained by a national Code Maintenance committee that meets when X12 meets for their trimester meetings to make decisions about additions, modifications, and retirement of existing reason codes.
Both code lists are updated three times a year, and are posted at http://wpc-edi.com/codes  . The lists at the end of this article summarize the latest changes to these lists, as announced in CR 5456, effective on and after April 1, 2007.
CMS has also developed a new tool to help you search for a specific category of code and that tool is at http://www.cmsremarkcodes.info . Note that this Web site does not replace the WPC site and, should there be any discrepancies between this site and the WPC site, consider the WPC site to be correct.
Additional Information
You can see the official instruction issued to your FI/carrier/DMERC/RHHI regarding these latest RARC and claim adjustment reason code updates by going to CR 5456, located at http://www.cms.hhs.gov/Transmittals/downloads/R1163CP.pdf  on the CMS Web site.
For additional information about Remittance Advice, please refer to Understanding the Remittance Advice (RA): A Guide for Medicare Providers, Physicians, Suppliers, and Billers at http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the CMS Web site.
If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  .
X12N 835 Remittance Advice Remark Code Changes
New Codes
| Code |
Current Narrative |
Medicare Initiated |
N373 |
It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf. Note: (New Code 12/1/06) |
No |
N374 |
Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required. Note: (New Code 12/1/06) |
No |
N375 |
Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility. Note: (New Code 12/1/06) |
No |
N376 |
Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE. Note: (New Code 12/1/06) |
No |
N377 |
Payment adjusted based on a processed replacement claim. Note: (New Code 12/1/06) |
No |
N378 |
Missing/incomplete/invalid prescription quantity. Note: (New Code 12/1/06) |
No |
N379 |
Claim level information does not match line level information. Note: (New Code 12/1/06) |
No |
Modified Codes
| Code |
Current Narrative |
Modification Date |
M143 |
The provider must update license information with the payer. Note: (Modified 12/1/06) |
12/01/06 |
N181 |
Additional information is required from another provider involved in this service. Note: (New Code 2/28/03. Modified 12/1/06) |
12/01/06 |
N361 |
Payment adjusted based on multiple diagnostic imaging procedure rules Note: (New Code 11/18/05. Modified 12/1/06) |
12/01/06 |
There are NO deactivated codes |
NOTE II: Some remark codes may provide information that may not necessarily supplement the explanation provided through a reason code and in some cases another/other remark code(s) for an adjustment. Newly created informational codes will have “Alert” in the text to identify them as informational rather than explanatory codes. An example of an informational code:
N369 Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
The above information is sent per state regulation, but does not explain any adjustment. These informational codes should be used only if specific information needs to be communicated but not as default codes.
X12 N 835 Health Care Claim Adjustment Reason Codes
New Codes
| Code |
Current Narrative |
Notes |
197 |
Payment denied/reduced for absence of precertification/authorization Note: New as of 10/06 |
New as of 10/06 |
198 |
Payment denied/reduced for exceeded, precertification/authorization Note: New as of 10/06 |
New as of 10/06 |
199 |
Revenue code and Procedure code do not match. Note: New as of 10/06 |
New as of 10/06 |
200 |
Expenses incurred during lapse in coverage Note: New as of 10/06 |
New as of 10/06 |
201 |
Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR). Note: New as of 10/06 |
New as of 10/06 |
Modified Codes
Code |
Current Narrative |
Notes |
42 |
Charges exceed our fee schedule or maximum allowable amount. Note: Changed as of 10/06. This code will be deactivated on 6/1/2007. |
Modified as of 10/06 Effective 6/1/2007 |
45 |
Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability). Note: Changed as of 10/06 |
Modified as of 10/06
Effective 6/1/2007
Note: This code replaces code 42 (above) on June 1, 2007. |
62 |
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Note: Changed as of 2/01 and 10/06. This code will be deactivated on 4/1/2007. |
Modified as of 10/06 |
97 |
Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated Note: Changed as of 2/99 and 10/06. |
Modified as of 10/06 |
107 |
Claim/service adjusted because the related or qualifying claim/service was not identified on this claim. Note: Changed as of 6/03 and 10/06. |
Modified as of 10/06 |
136 |
Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA). Note: Changed as of 6/00 and 10/06. |
Modified as of 10/06 |
196 |
Claim/service denied based on prior payer's coverage determination. Note: New as of 6/06. Changed 10/06. This code will be deactivated on 2/1/2007, beginning on that date, value 136 will be used. |
Modified as of 10/06 |
A1 |
Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code). Note: Changed as of 10/06. |
Modified as of 10/06 |
B15 |
Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Changed as of 2/01 and 10/06. |
Modified as of 10/06 |
D17 |
Claim/Service has invalid non-covered days. Note: This code will be deactivated on 2/1/2007 and code 16 will then be used with appropriate claim payment remark code [M32, M33]. |
Modified as of 10/06 |
D18 |
Claim/Service has missing diagnosis information. Note: This code will be deactivated on 2/1/2007 and then code 16 will be used with appropriate claim payment remark code [MA63, MA65]. |
Modified as of 10/06 |
D19 |
Claim/Service lacks Physician/Operative or other supporting documentation Note: This code will be deactivated on 2/1/2007 and code 16 will be used with appropriate claim payment remark code [M29, M30, M35, M66]. |
Modified as of 10/06 |
D20 |
Claim/Service missing service/product information. Note: This code will be deactivated on 2/1/2007 and code 16 will be used with appropriate claim payment remark code [M20, M67, M19, MA67]. |
Modified as of 10/06 |
D21 |
This (these) diagnosis(es) is (are) missing or are invalid Note: New as of 6/05. This code will be deactivated on 2/1/2007. |
Modified as of 10/06 |
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5456
Pub. 100-4, Transmittal# R1163CP, CR# 5456
Related CR Release Date: January 26, 2007
Effective Date: April 1, 2007
Implementation Date: April 2, 2007
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