MLN Matters Number: MM6109
Related Change Request (CR) #: 6109
Related CR Release Date: July 25, 2008
Effective Date: October 1, 2008
Related CR Transmittal #: R1563CP
Implementation Date: October 6, 2008
Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Part A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for services.
Impact on Providers
CR 6109, from which this article is taken, announces the latest update of Remittance Advice Remark Codes (RARC) used in electronic and paper remittance advice, and Claim Adjustment Reason Codes (CARC) used in electronic and paper remittance advice and coordination of benefits (COB) claim transactions. These changes will be effective October 1, 2008.
Be sure that your billing staffs are aware of these changes.
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 coordination-of-benefits (COB) transactions.
The RARC list is maintained by the Centers for Medicare & Medicaid Services (CMS), and used by all payers; and additions, deactivations, and modifications to it may be initiated by any health care organization. The CARC 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 on the Washington Publishing Company (WPC) Web site at www.wpc-edi.com/Codes on the Internet. The tables at the end of this article (right after the 'Additional Information' section) summarize the latest changes to these lists, as announced in CR6109.
CMS has also developed a tool to help you search for a specific category of RARC code and that tool is available at www.cmsremarkcodes.info on the Internet. Note that this Web site does not replace the WPC site and, should there be any discrepancies in what is posted at this site and the WPC site, consider the WPC site to be correct.
Additional Information
To see the official instruction (CR 6109) issued to your Medicare Carrier, RHHI, DME/MAC, FI and/or A/B MAC refer to www.cms.hhs.gov/Transmittals/downloads/R1563CP.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 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 our provider service center at our toll-free number, (877) 567-9249 (for North Carolina and South Carolina Part A providers) or (866) 801-5301 (for home health and hospice providers).
The changes that are effective on October 1, 2008 are shown in the following tables.
Remittance Advice Remark Code changes
New Codes
|
Code
|
Current Narrative
|
Medicare Initiated
|
|
N433
|
Resubmit this claim using only your National Provider Identifier (NPI)
|
Y
|
Modified Codes
|
Code
|
Current Modified Narrative
|
Last Modified
|
|
MA97
|
Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.
|
2/29/08
|
|
N175
|
Missing review organization approval.
|
2/29/08
|
|
N241
|
Incomplete/invalid review organization approval.
|
2/29/08
|
|
N421
|
Claim payment was the result of a payer's retroactive adjustment due to a review organization decision.
|
2/29/08
|
Deactivated Codes
|
Code
|
Current Narrative
|
Last Modified
|
|
None
|
|
|
Health Care Claim Adjustment Reason Codes
New Codes
|
Code
|
Current Narrative
|
Effective Date
(per WPC Web site)
|
|
213
|
Non-compliance with the physician self referral prohibition legislation or payer policy.
|
1/27/2008
|
|
214
|
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. (Note: To be used for Workers' Compensation only)
|
1/27/2008
|
|
215
|
Based on subrogation of a third party settlement
|
1/27/2008
|
|
216
|
Based on the findings of a review organization
|
1/27/2008
|
|
217
|
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only)
|
1/27/2008
|
|
218
|
Based on entitlement to benefits (Note: To be used for Workers' Compensation only)
|
1/27/2008
|
|
219
|
Based on extent of injury (Note: To be used for Workers' Compensation only)
|
1/27/2008
|
|
220
|
The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only)
|
1/27/2008
|
|
221
|
Workers' Compensation claim is under investigation. (Note: To be used for Workers' Compensation only. Claim pending final resolution)
|
1/27/2008
|
|
D22
|
Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code
|
1/27/2008
|
Modified Codes
|
Code
|
Modified Narrative
|
Effective Date
(per WPC Web site)
|
|
151
|
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
|
1/27/2008
|
Deactivated Codes
|
Code
|
Current Narrative
|
Effective Date (per WPC Web site)
|
|
D22
|
Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code
|
1/1/2009
|
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.