Denosumab (Prolia) J0897 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.
Prolia — 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 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 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. |
| 5D920 | 5H920 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40. |
| 5D169 | 5H169 | 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. | Services Not Documented. | GA104 | 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 | 5H151 | 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. | 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 | 5H199 | 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 | 5HMDP | Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15. | Dependent, qualifying srvc medically denied. | GAJ02 | Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15. |
| 5DTDP | 5HTDP | Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15. | Dependent, qualifying srvc technically denied. | GAJ02 | Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15. |