39132

Description:
This is an outpatient claim (Type of Bill 12X, 13X, or 14X) in which the Outpatient Prospective Payment System (OPPS) reimbursement is greater than the covered charges reported on the claim.

MLN Matters Article 7771 (PDF, 87 KB) created Reason Code 39132 as a verification edit for development. MACs will suspend those claims receiving this edit to determine billing accuracy and that the OPPS reimbursement is not excessive. The claim is returned to the provider (RTP) with Reason Code 39132 for provider verification.

Resolution:

  • Access the RTP claim. The Remarks section will include the code(s) in question.
  • Verify that the code(s), unit(s) and charges* are reported correctly
    • The line item charge for the code should be reported correctly, even if the code is a packaged service
  • If correct, enter the verbiage "Charges have been verified" in Remarks and F9/resubmit the claim
  • If any of the line item information was reported incorrectly, correct the information and F9/resubmit the claim

Once verified and returned to the MAC, the claim will suspend to the Manual Location S MREM for review. If it is determined that the billing is accurate and the reimbursement is not excessive, the edit will be override and continue to process the claim.

*In most cases, the unit of payment under the OPPS is the APC. CMS assigns individual services (Healthcare Common Procedure Coding System [HCPCS] codes) to APCs based on similar clinical characteristics and similar costs. The payment rate and copayment calculated for an APC apply to each service within the APC.

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