Palmetto GBA - Regional Home Health & Hospice Intermediary (RHHI) - Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update (Effective Date January 1, 2009)

Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update (Effective Date January 1, 2009)

MLN Matters Number: MM6229
Related Change Request (CR) #: 6229
Related CR Release Date: November 14, 2008
Effective Date: January 1, 2009
Related CR Transmittal #: R1634CP
Implementation Date: January 5, 2009

Provider Types Affected

Physicians, providers, and suppliers submitting claims to Medicare contractors (Carriers, DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.

Provider Action Needed

This article is based on Change Request (CR) 6229 which updates Remittance Advice Remark Codes (RARCs) and Claim Adjustment Reason Codes (CARCs). If you use the Medicare Remit Easy Print software, note that Medicare will update that software as a result of implementing CR6229. Be sure billing staff are aware of these updates.

Background

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy states that Claim Adjustment Reason Codes (CARCs) are required in the remittance advice and coordination of benefits transactions. Medicare policy further states that appropriate Remittance Advice Remark Codes (RARCs) that provide either supplemental explanation for a monetary adjustment or policy information are required in the remittance advice transaction.

X12N 835 Health Care Remittance Advice Remark Codes

The Centers for Medicare & Medicaid Services (CMS) is the national maintainer of the remittance advice remark code list. This code list is used by reference in the ASC X12 N transaction 835 (Health Care Claim Payment/Advice) version 004010A1 Implementation Guide (IG). Under HIPAA, all payers, including Medicare, are required to use reason and remark codes approved by X12 recognized code set maintainers instead of proprietary codes to explain any adjustment in the claim payment. CMS, as the X12 recognized maintainer of RARCs, receives requests from Medicare and non-Medicare payers for new codes and modification/deactivation of existing codes. Additions, deletions, and modifications to the code list resulting from non-Medicare requests may or may not impact Medicare.
Note: The complete list of remark codes is available at http://www.wpc-edi.com/codes on the Internet.

Medicare contractors will use the latest approved and valid codes in the 835, corresponding Standard Paper Remittance (SPR) advice, and coordination of benefits transactions.

CMS has developed a new Web site to help navigate the RARC database more easily. A tool is provided to help search if you are looking for a specific category of codes. At this site you can find some other information that is also available from the WPC Web site. The Web site address is http://www.cmsremarkcodes.info/ on the Internet.

NOTE I: This Web site is not replacing the WPC Web site as the official site where the most current RARC list resides. If there is any discrepancy, always use the list posted at the WPC Web site.

NOTE II: Some remark codes may only provide general information that may not necessarily supplement the specific explanation provided through a reason code and in some cases another/other remark code(s) for a monetary adjustment. Codes that are “Informational” will have “Alert” in the text to identify them as informational rather than explanatory codes. These “Informational” codes may be used without any CARC explaining a specific adjustment.

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 are used only if specific information about adjudication (like appeal rights) needs to be communicated but not as default codes when a RARC is required with a CARC -16, 17, 96, 125, and A1.

Remittance Advice Remark Code Changes

New Codes:

Code	Current Narrative	Medicare Initiated
N434	Missing/Incomplete/Invalid Present on Admission indicator. Start: 7/1/2008
N435	Exceeds number/frequency approved /allowed within time period without support documentation. Start: 7/1/2008
N436	The injury claim has not been accepted and a mandatory medical reimbursement has been made. Start: 7/1/2008
N437	Alert: If the injury claim is accepted, these charges will be reconsidered. Start: 7/1/2008
N438	This jurisdiction only accepts paper claims. Start: 7/1/2008
N439	Missing anesthesia physical status report/indicators. Start: 7/1/2008
N440	Incomplete/invalid anesthesia physical status report/indicators. Start: 7/1/2008
N441	This missed appointment is not covered. Start: 7/1/2008
N442	Payment based on an alternate fee schedule. Start: 7/1/2008
N443	Missing/incomplete/invalid total time or begin/end time. Start: 7/1/2008
N444	Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation. Start: 7/1/2008
N445	Missing document for actual cost or paid amount. Start: 7/1/2008
N446	Incomplete/invalid document for actual cost or paid amount. Start: 7/1/2008
N447	Payment is based on a generic equivalent as required documentation was not provided. Start: 7/1/2008
N448	This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement. Start: 7/1/200
N449	Payment based on a comparable drug/service/supply. Start: 7/1/2008
N450	Covered only when performed by the primary treating physician or the designee. Start: 7/1/2008
N451	Missing Admission Summary Report. Start: 7/1/2008
N452	Incomplete/invalid Admission Summary Report. Start: 7/1/2008
N453	Missing Consultation Report. Start: 7/1/2008
N454	Incomplete/invalid Consultation Report. Start: 7/1/2008
N455	Missing Physician Order. Start: 7/1/2008
N456	Incomplete/invalid Physician Order. Start: 7/1/2008
N457	Missing Diagnostic Report. Start: 7/1/2008
N458	Incomplete/invalid Diagnostic Report. Start: 7/1/2008
N459	Missing Discharge Summary. Start: 7/1/2008
N460	Incomplete/invalid Discharge Summary. Start: 7/1/2008
N461	Missing Nursing Notes. Start: 7/1/2008
N462	Incomplete/invalid Nursing Notes. Start: 7/1/2008
N463	Missing support data for claim. Start: 7/1/2008
N464	Incomplete/invalid support data for claim. Start: 7/1/2008
N465	Missing Physical Therapy Notes/Report. Start: 7/1/2008
N466	Incomplete/invalid Physical Therapy Notes/Report. Start: 7/1/2008
N467	Missing Report of Tests and Analysis Report. Start: 7/1/2008
N468	Incomplete/invalid Report of Tests and Analysis Report. Start: 7/1/2008
N469	Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Start: 7/1/2008	YES
N470	This payment will complete the mandatory medical reimbursement limit. Start: 7/1/2008
N471	Missing/incomplete/invalid HIPPS Rate Code. Start: 7/1/2008
N472	Payment for this service has been issued to another provider. Start: 7/1/2008
N473	Missing certification. Start: 7/1/2008
N474	Incomplete/invalid certification Start: 7/1/2008
N475	Missing completed referral form. Start: 7/1/2008
N476	Incomplete/invalid completed referral form Start: 7/1/2008
N477	Missing Dental Models. Start: 7/1/2008
N478	Incomplete/invalid Dental Models Start: 7/1/2008
N479	Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). Start: 7/1/2008
N480	Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). Start: 7/1/2008
N481	Missing Models. Start: 7/1/2008
N482	Incomplete/invalid Models Start: 7/1/2008
N483	Missing Periodontal Charts. Start: 7/1/2008
N484	Incomplete/invalid Periodontal Charts Start: 7/1/2008
N485	Missing Physical Therapy Certification. Start: 7/1/2008
N486	Incomplete/invalid Physical Therapy Certification. Start: 7/1/2008
N487	Missing Prosthetics or Orthotics Certification. Start: 7/1/2008
N488	Incomplete/invalid Prosthetics or Orthotics Certification Start: 7/1/2008
N489	Missing referral form. Start: 7/1/2008
N490	Incomplete/invalid referral form Start: 7/1/2008
N491	Missing/Incomplete/Invalid Exclusionary Rider Condition. Start: 7/1/2008
N492	Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge. Start: 7/1/2008
N493	Missing Doctor First Report of Injury. Start: 7/1/2008
N494	Incomplete/invalid Doctor First Report of Injury. Start: 7/1/2008
N495	Missing Supplemental Medical Report. Start: 7/1/2008
N496	Incomplete/invalid Supplemental Medical Report. Start: 7/1/2008
N497	Missing Medical Permanent Impairment or Disability Report. Start: 7/1/2008
N498	Incomplete/invalid Medical Permanent Impairment or Disability Report. Start: 7/1/2008
N499	Missing Medical Legal Report. Start: 7/1/2008
N500	Incomplete/invalid Medical Legal Report. Start: 7/1/2008
N501	Missing Vocational Report. Start: 7/1/2008
N502	Incomplete/invalid Vocational Report. Start: 7/1/2008
N503	Missing Work Status Report. Start: 7/1/2008
N504	Incomplete/invalid Work Status Report. Start: 7/1/2008

Modified Codes

Code	Current Modified Narrative	Last Modified
M29	Missing operative note/report.	7/1/08
N10	Payment based on the findings of a review organization/professional consult/manual adjudication/medical or dental advisor.	7/1/08
N26	Missing itemized bill/statement.	7/1/08
N40	Missing radiology film(s)/image(s).	7/1/08
N130	Alert: Consult plan benefit documents/guidelines for information about restrictions for this service.	7/1/08
N209	Missing/incomplete/invalid taxpayer identification number (TIN).	7/1/08
N232	Incomplete/invalid itemized bill/statement.	7/1/08
N233	Incomplete/invalid operative note/report.	7/1/08
N242	Incomplete/invalid radiology film(s)/image(s).	7/1/08
N350	Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.	7/1/08
N367	Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.	7/1/08
N390	This service/report cannot be billed separately	7/1/08
N393	Missing progress notes/report	7/1/08
N394	Incomplete/invalid progress notes/report.	7/1/08

Deactivated Codes

There are no newly deactivated codes with CR 6229. Lists of all deactivated and scheduled to be deactivated RARCs are available at the WPC Web site at http://www.wpc-edi.com/codes on the Internet.

X12 N 835 Health Care Claim Adjustment Reason Codes

A national code maintenance committee maintains the health care Claim Adjustment Reason Codes (CARCs). The Committee meets at the beginning of each X12 trimester meeting (January/February, June and September/October) and makes decisions about additions, modifications, and retirement of existing reason codes. The updated list is posted 3 times a year around early November, March, and July.

The list is available at http://www.wpc-edi.com/codes on the Internet.

New Codes:

Code	Current Narrative	Implementation Date
222	Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Start Date: 6/1/2008	1/5/2009
223	Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Start Date: 6/1/2008	1/5/2009
224	Patient identification compromised by identity theft. Identity verification required for processing this and future claims. Start Date: 6/1/2008	1/5/2009
225	Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) Start Date: 6/1/2008	1/5/2009

Note: Codes 223 and 224 are Medicare initiated

Modified Code(s):

Code	Modified Narrative	Implementation Date
60	Charges for outpatient services with this proximity to inpatient services are not covered. This change to be effective 1/1/2009: Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.	1/5/2009

Deactivated Code(s):

Code	Modified Narrative	Implementation Date
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 Start: 01/27/2008 \| Stop: 01/01/2009	1/1/2009

NOTE: The Code Committee also reactivated CARC 207

Additional Information

The official instruction, CR6229, issued to your Carrier, FI, A/B MAC, RHHI, and DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1634CP.pdf on the CMS Web site.

If you have any questions, please contact our provider service center at our toll-free number, 1-877-567-9249 (for North Carolina Part A and South Carolina Part providers) or 1-866-801-5301 (for home health and hospice providers).

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.

last updated on 11/21/2008

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