Outpatient Therapy: Denial 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 the 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.

Outpatient Therapy — 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
5D169 5H169 The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2. Services Not Documented. GAI10 The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2.
5D169 5H169 The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2. Services Not Documented. GAI11 The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2.
5D164 5H164 The documentation submitted did not include signed documentation to support the medical necessity of the services provided. Refer to Medicare Program Integrity Manual (Pub.100-08) Chapter 3, Section 3.3.2.4, Social Security Act 1862(a)(1)(A). Doc submitted does not support med neccessity. GAI12 The documentation submitted did not include signed documentation to support the medical necessity of the services provided. Refer to Medicare Program Integrity Manual (Pub.100-08) Chapter 3, Section 3.3.2.4, Social Security Act 1862(a)(1.)(A)
5D164 5H164 The submitted documentation 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. Doc submitted does not support med neccessity. GAJ01  The submitted documentation 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.
5D169 5H169 Provider did not submit all requested documentation. 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€. Services not documented. GAI01  Provider did not submit all requested documentation. 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)
5FFSG 5CFSG The documentation submitted did not support signature requirements were met.
Refer to: Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.3.2.4; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.3B.
Missing/Illegible Signature . GAI07 The documentation submitted did not support signature requirements were met.
Refer to: Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.3.2.4; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.3B.
5D162 5D162 Insufficient/Incomplete information. Refer to: 42 CFR 424.5(a)(6); SSA 1833(e); Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.2.3.8 C; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.1.2. No Valid Plan of Care. GAI03  Insufficient/Incomplete information. Refer to: 42 CFR 424.5(a)(6); SSA 1833(e); Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.2.3.8 C; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.1.2.
5D165 5D165 The documentation submitted did not include the required certifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3. No Certification. GAM01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3.
5D920 5D920 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€. The recommended protocol was not ordered and/or followed. 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€.
5D920 5D920 The documentation submitted did not support the service(s) billed as being rendered. Refer to Internet-Only Manuals-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A. The recommended protocol was not ordered and/or followed. GAI04 The documentation submitted did not support the service(s) billed as being rendered. Refer to Internet-Only Manuals-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A.
5D151 5D151 The documentation submitted does not support the number of units billed. Refer to "Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 (coding determinations) and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 (description of HCPCS); AMA CPT Professional coding guidelines PUB 100-4 Ch 4 Section 20.4 (UOS), 42 CFR Section 414.40, AMA HCPCS Professional coding guidelines. Units Billed More Than Ordered. GAK04 The documentation submitted does not support the number of units billed. Refer to "Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 (coding determinations) and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 (description of HCPCS); AMA CPT Professional coding guidelines PUB 100-4 Ch 4 Section 20.4 (UOS), 42 CFR Section 414.40, AMA HCPCS Professional coding guidelines.
5D199  5D199  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. 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.
5DMDP 5DMDP Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15. Dependent qualifying services medically denied. GAJ02  Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.
5DTDP 5DTDP Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15. Dependent qualifying services medically denied. GAJ02  Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.