Diagnosis Related Group (DRG) 885 Reason Code Crosswalk

Published 05/04/2020

Palmetto GBA is currently updating systems to incorporate the standardized  CMS reason codes and statements. In the interim, please see below list of Palmetto GBA denial codes and the corresponding CMS reason codes and statements. For more information related to CMS reason codes, please refer to the CMS website.

DRG 885 — Denial Reason Crosswalk

 

Palmetto GBA Full Denial Code Palmetto GBA Partial Denial Code Palmetto GBA Granular Denial Reason Palmetto Denial Description CMS Reason Code CMS Statement
5J502 5K502 GAI11: The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2. Info submitted does not support dates billed. GAI11 The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2.
5J502 5K502 GAI10: The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2. Info submitted does not support dates billed. GAI10 The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2.
5D650 5H650 No valid certification present. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 certification invalid. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 Invalid certification. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 Certification invalid. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 No valid recertification present. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 Recertification not submitted. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 No valid recertification present. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D650 5H650 No valid recertification present. No Valid Certification or Recertification Present. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D800 N/A No initial psychiatric evaluation submitted. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D800 N/A No initial psychiatric evaluation. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D800 N/A The initial psychiatric evaluation submitted incomplete. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D800 N/A Initial psychiatric evaluation not submitted. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D800 N/A No valid initial psychiatric evaluation submitted. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D800 N/A Initial psychiatric evaluation submitted incomplete. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D800 N/A Initial psychiatric evaluation submitted is not complete. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D700 N/A No valid treatment plan present. No Valid Plan of Treatment Present. GAI03 Incomplete/Insufficient information. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e).
5D700 N/A Treatment plan does not include a diagnosis. No Valid Plan of Treatment Present. GAI03 Incomplete/Insufficient information. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e).
5D700 N/A Treatment plan does not include goals. No Valid Plan of Treatment Present. GAI03 Incomplete/Insufficient information. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e).
5D700 N/A Treatment plan does not include documentation of treatment modalities and the responsibilities of team members in those modalities. No Valid Plan of Treatment Present. GAI03 Incomplete/Insufficient information. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e).
5D800 N/A No interdisciplinary progress notes to support medical necessity of services. Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services. GAJ01 The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D199 N/A All or part of the claim was billed in error by the provider. Billing Error. GAK09 Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23.