Diagnosis Related Group (DRG 470) 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 470 — 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 | 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. |
| 5J504 | 5K504 | GAJ01: The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to SSA 1862(a)(1)(A; IOM-Pub 100-08, Chp 3, Sec 3.6.2.1, 3.6.2.2 & 3.4.1.3. | Need for service or item not medically and reasonable necessary. | 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 | 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. | Billing error for hospital. | 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. |