MLN Matters Number: MM5800 |
Related Change Request (CR) #:
5800 |
Related CR Release Date: November
30, 2007 |
Effective Date: January 1, 2008
|
Related CR Transmittal #: R1384CP
|
Implementation Date: January
7, 2008 |
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), and Durable Medical Equipment Medicare Administrative
Contractors (DME MAC)) for services
Impact on Providers
CR 5800, from which this article is taken, announces the latest
update of Remittance Advice Remark Codes used in electronic and
paper remittance advice and Claim Adjustment Reason Codes used in
electronic and paper remittance advice and coordination of benefits
(COB) claim transactions. These changes will be effective January
1, 2008. Be sure billing staff are aware of these changes.
Background
Two code sets—the reason and remark code sets—must
be used to report payment adjustments in remittance advice transactions.
The reason codes are also used in some coordination-of-benefits
transactions.
The remittance advice remark code 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
on the Internet. The lists at the end of this article summarize
the latest changes to the remark code lists, as announced in CR
5800, effective on January 1, 2008. As a reminder, CMS notes that
the claim adjustment reason code of A2 (Contractual adjustment)
is deactivated effective January 1, 2008.
CMS has developed a new website to help navigate the RARC database
more easily. A tool is provided to help search if you are looking
for a specific category of code. At this site, you can find some
other information that is also available from the Washington Publishing
Company (WPC) Web site. The new Web site address is http://www.cmsremarkcodes.info/
on the Internet.
Note that this Web site does not replace the Washington Publishing
Company (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 may see the official instruction (CR5800) issued to your Medicare
Carrier, A/B MAC, FI, DME MAC or RHHI by going to http://www.cms.hhs.gov/Transmittals/downloads/R1384CP.pdf
on the CMS Web site.
If you have questions, please contact your Medicare A/B MAC, carrier,
FI, DME MAC or RHHI at their toll-free number which may be found
at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip
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.
Remittance Advice Remark Code Changes
New Codes
| Code |
Current Narrative |
Comment |
N388 |
Missing/incomplete/invalid prescription number.
Note: (New Code 8/1/07) |
Medicare initiated |
N389 |
Duplicate prescription number submitted. Note:
(New Code 8/1/07) |
Medicare initiated |
N390 |
This service cannot be billed separately.
Note: (New Code 8/1/07) |
Medicare initiated |
N391 |
Missing emergency department records. Note:
(New Code 8/1/07) |
Not Medicare initiated |
N392 |
Incomplete/invalid emergency department records.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N393 |
Missing progress notes or report. Note:
(New Code 8/1/07) |
Not Medicare initiated |
N394 |
Incomplete/invalid progress notes or report.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N395 |
Missing laboratory report. Note: (New
Code 8/1/07) |
Not Medicare initiated |
N396 |
Incomplete/invalid laboratory report. Note:
(New Code 8/1/07) |
Not Medicare initiated |
N397 |
Benefits are not available for incomplete
service(s)/undelivered item(s). Note: (New Code 8/1/07)
|
Not Medicare initiated |
N398 |
Missing elective consent form. Note:
(New Code 8/1/07) |
Not Medicare initiated |
N399 |
Incomplete/invalid elective consent form.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N400 |
Alert: Electronically enabled providers should
submit claims electronically. Note: (New Code 8/1/07)
|
Not Medicare initiated |
N401 |
Missing periodontal charting. |
Not Medicare initiated |
Note: (New Code 8/1/07)
|
N402 |
Incomplete/invalid periodontal
charting. Note: (New Code 8/1/07) |
Not Medicare initiated |
N403 |
Missing facility certification.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N404 |
Incomplete/invalid facility certification.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N405 |
This service is only covered when
the donor's insurer(s) do not provide coverage for the service.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N406 |
This service is only covered when
the recipient's insurer(s) do not provide coverage for the
service. Note: (New Code 8/1/07) |
Not Medicare initiated |
N407 |
You are not an approved submitter
for this transmission format. Note: (New Code 8/1/07)
|
Medicare Initiated |
N408 |
This payer does not cover deductibles
assessed by a previous payer. Note: (New Code 8/1/07)
|
Not Medicare initiated |
N409 |
This service is related to an
accidental injury and is not covered unless provided within
a specific time frame from the date of the accident. Note:
(New Code 8/1/07) |
Not Medicare initiated |
N410 |
This is not covered unless the
prescription changes. Note: (New Code 8/1/07) |
Not Medicare initiated |
N411 |
This service is allowed one time
in a 6-month period. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N412 |
This service is allowed 2 times
in a 12-month period. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N413 |
This service is allowed 2 times
in a benefit year. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N414 |
This service is allowed 4 times
in a 12-month period. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N415 |
This service is allowed 1 time
in an 18-month period. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N416 |
This service is allowed 1 time
in a 3-year period. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N417 |
This service is allowed 1 time
in a 5-year period. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.) Note:
(New Code 8/1/07) |
Not Medicare initiated |
N418 |
Misrouted claim. See the payer's
claim submission instructions. Note: (New Code 8/1/07)
|
Not Medicare initiated |
N419 |
Claim payment was the result of
a payer's retroactive adjustment due to a retroactive rate
change. Note: (New Code 8/1/07) |
Not Medicare initiated |
N420 |
Claim payment was the result of
a payer's retroactive adjustment due to a Coordination of
Benefits or Third Party Liability Recovery. Note:
(New Code 8/1/07) |
Not Medicare initiated |
N421 |
Claim payment was the result of
a payer's retroactive adjustment due to a Peer Review Organization
decision. Note: (New Code 8/1/07) |
Not Medicare initiated |
N422 |
Claim payment was the result of
a payer's retroactive adjustment due to a payer's contract
incentive program. Note: (New Code 8/1/07) |
Not Medicare initiated |
N423 |
Claim payment was the result of
a payer's retroactive adjustment due to a non standard program.
Note: (New Code 8/1/07) |
Not Medicare initiated |
N424 |
Patient does not reside in the
geographic area required for this type of payment. Note:
(New Code 8/1/07) |
Medicare initiated |
N425 |
Statutorily excluded service(s).Note:
(New Code 8/1/07) |
Medicare initiated |
N426 |
No coverage when self-administered.
Note: (New Code 8/1/07) |
Medicare initiated |
N427 |
Payment for eyeglasses or contact
lenses can be made only after cataract surgery. Note:
(New Code 8/1/07) |
Medicare initiated |
N428 |
Service/procedure not covered
when performed in this place of service. Note: (New
Code 8/1/07) |
Medicare initiated |
N429 |
This is not covered since it is
considered routine. Note: (New Code 8/1/07) |
Medicare initiated |
* NOTE: Some remark codes may provide only information.
They may not necessarily supplement the explanation provided through
a reason code, or, in some cases another/other remark code(s), for
an adjustment. Codes that are informational will have “Alert”
in the text to identify them as informational rather than explanatory
codes. For example, this informational code is sent per state regulation,
but does not explain any adjustment:
N369 Alert: Although this claim has been processed, it is
deficient according to state legislation/regulation.
These informational codes will be used only if specific information
needs to be communicated but not as default codes
Modified Codes
| Code |
Current Modified Narrative
|
Comment |
M27 |
Alert: The
patient has been relieved of liability of payment of these
items and services under the limitation of liability provision
of the law. The provider is ultimately liable for the patient's
waived charges, including any charges for coinsurance, since
the items or services were not reasonable and necessary or
constituted custodial care, and you knew or could reasonably
have been expected to know, that they were not covered. You
may appeal this determination. You may ask for an appeal regarding
both the coverage determination and the issue of whether you
exercised due care. The appeal request must be filed within
120 days of the date you receive this notice. You must make
the request through this office. |
Modified 10/1/02, 8/1/05, 4/1/07,
8/1/07 |
M70 |
Alert: The patient is a
member of an employer-sponsored prepaid health plan. Services
from outside that health plan are not covered. However, as
you were not previously notified of this, we are paying this
time. In the future, we will not pay you for non-plan services.
|
Modified 4/1/07, 8/1/07 |
MA14 |
Alert: The patient is a
member of an employer-sponsored prepaid health plan. Services
from outside that health plan are not covered. However, as
you were not previously notified of this, we are paying this
time. In the future, we will not pay you for non-plan services.
|
Modified 4/1/07, 8/1/07 |
M62 |
Alert: This is a telephone
review decision. |
Modified 4/1/07, 8/1/07 |
N12 |
Policy provides coverage supplemental to Medicare.
As the member does not appear to be enrolled in the applicable
part of Medicare, the member is responsible for payment of
the portion of the charge that would have been covered by
Medicare.) |
Modified 8/1/07 |
N84 |
Alert: Further installment
payments are forthcoming. |
Modified 4/1/07, 8/1/07 |
N85 |
Alert: This is the final
installment payment. |
Modified 4/1/07, 8/1/07 |
N129 |
Not eligible due to the patient's age. |
New Code 10/31/02, Modified 8/1/07 |
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.
News Flash - It's seasonal flu time
again! If you have Medicare patients who haven't yet received their
flu shot, you can help them reduce their risk of contracting the
seasonal flu and potential complications by recommending an annual
influenza and a one - time pneumococcal vaccination. Medicare provides
coverage for flu and pneumococcal vaccines and their administration.
-And don't forget to immunize yourself and your staff . Protect
yourself, your patients, and your family and friends. Get Your Flu
Shot-Not the Flu! Remember - Influenza vaccination is
a covered Part B benefit but the influenza vaccine is NOT a Part
D covered drug. Health care professionals and their staff can learn
more about Medicare's coverage of adult immunizations and related
provider education resources, by reviewing Special Edition MLN
Matters article SE0748 http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf
on the CMS Web site .
Posted: 12/07/2007
|
