Medical Review Reason Code Crosswalk

Palmetto GBA/Railroad Medicare is currently updating systems to incorporate the standardized CMS reason codes and statements. In the interim, please see the following 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 at https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Review-Reason-Codes-and-Statements.html

 

MR - Denial Reason Code Chart
Denial Reason Denial Code Verbiage on Provider Reports CMS Reason Code CMS Statement Verbiage on Provider Remittance Advice Additional Provider Remittance Advice Information
Medical Necessity
Provider Indicated Claim Billed In Error BILER Claim billed in error per Provider. GBD01 Billing Error. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4; 100-04 Medicare Claims Processing Manual, Chapter 23. 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review
GBD14 The provider indicated services were billed in error. Refer to Section 1833 (e),
Title XVIII, of the Social Security Act
   
Maintenance THeraPY MTHPY These charges are non-covered services; documentation supports Maintenance Therapy. GBC04 The documentation provided does not support the medical necessity for this number of services or items within this timeframe. Refer to SSA 1862, IOM, 100-08, MPIM Chapter 3, Section 3.6.2.2 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review
GBC05 The maximum benefit has been reached for this service. Refer to IOM, Pub 100-02, Medicare Benefit Policy Manual Chapter 5 and IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5 A    
Documentation does NOT support Medical Necessity NOTMN Payer deems the information submitted does not support medical necessity of services billed. GBC02 The documentation submitted does not support medical necessity. Refer to SSA
1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section
3.6.2.1, 3.6.2.2
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review
GBD10 The documentation does not support that a separately identifiable service was performed. Refer to IOM Medicare Claims Processing Manual Chapter 12, Section 30.6; Section 1833 (e), Title XVIII, of the Social Security Act    
GBD16 The service or device was not FDA approved. Refer to SSA 1862; Medicare Benefit Policy Manual Chapter 14    
Transportation does not meet minimum requirements for Medicare coverage TRMIN Payer deems the information submitted does not support medical necessity of services billed. GBD09 The documentation submitted does not support the ordered service. Refer to IOM-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review
Alternative Services were AVAilable and should have been utilized. ASAVA Alternative services were available and should have been utilized. GBC01 The documentation submitted does not support medical necessity as listed in coverage requirement. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.2 B8: Alternative services were available and should have been utilized. N109: This claim was chosen for complex review.
Transportation is only covered to the closest facility that can provide the necessary care. ATCCF Transportation is only covered to the closest facility that can provide the necessary care. GBB11 The documentation submitted does not support the number of units billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 117: Transportation is only covered to the closest facility that can provide the necessary care.  
Not covered by Part B - Preventive NOPRV Services not covered by Part B Medicare. GBC06 The documentation indicates that the service was performed for routine/screening purposes but is not covered under Medicare’s Screening Benefit. Refer to Medicare Claims Processing Manual Chapter 18. 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review
GBD12 The documentation submitted indicates the service was performed for cosmetic purposes. Refer to Medicare Benefit Policy Manual Chapter 16, Section 120    
Not covered by Part B - Pre-Operative NOPOP Services not covered by Part B Medicare. GBC06 The documentation indicates that the service was performed for routine/screening purposes but is not covered under Medicare’s Screening Benefit. Refer to Medicare Claims Processing Manual Chapter 18. 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review
More than one service billed with modifier 26 & with no supporting medical necessity. NOSUP More than one service billed with modifier 26 & with no supporting medical necessity. GBC04 The documentation provided does not support the medical necessity for this number of services or items within this timeframe. Refer to SSA 1862, IOM, 100-08, MPIM Chapter 3, Section 3.6.2.2 151: Payment adjusted b/c the payer deems the info submitted does not support this many services.  
Documentation Issues
NO ORDer NOORD Documentation lacks the necessary provider order. GBB04 The documentation submitted did not include a physician order. Refer to IOM, Pub 100-08, Chapter 3, Section 3.6.2.2 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N455: Missing Physician Order
ORiginal Document Not Received ORDNR Information received lacks the necessary patient medical record GBB01 The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. M127: Missing patient medical record for this service. N109: This claim was chosen for complex review
Invalid physician certification statement (PCS not signed, incomplete, or invalid) INPCS Documentation requested for this date of service was incomplete. GBG01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N29: Missing documentation/orders/notes/summary/report/chart. N109: This claim was chosen for complex review
NO Certificate of Medical Necessity/PCS received. NOPCS Documentation received lacks the necessary Certificate of Medical Necessity GBG01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N29: Missing documentation/orders/notes/summary/report/chart N109: This claim was chosen for complex review
No or partial DOCumentation received NODOC Documentation requested for this date of service was not received or was incomplete. GBB01 The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N29: Missing documentation/orders/notes/summary/report/chart N109: This claim was chosen for complex review
GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C    
INvalid provider Plan Of Care (treatment plan) INPOC Documentation received contains an invalid/ incomplete provider plan of care. GBG01 The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N238: Incomplete/invalid physician certified plan of care
ILlegible DOCumentation ILDOC Information submitted deemed illegible. GBB10 The documentation submitted is not legible. Refer to Medicare Program Integrity Manual, Chapter 3 Section 3.3.2.1 50:These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N237: Incomplete/Invalid patient medical record for this service.
Incorrect/Incomplete/Invalid mileage (use when denying partial mileage) INMIL Documentation received contains incorrect/incomplete/invalid mileage. GBB11 The documentation submitted does not support the number of units billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 50:These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N237: Incomplete/Invalid patient medical record for this service.
Inconsistent information; WRONG patient or WRONG DOS. WRONG Documentation received contains incorrect/incomplete/invalid patient identification or date of service GBB05 The documentation submitted was missing patient identifiers. Refer to Standards for Adequacy of Medical Records; Section 1833 (e), Title XVIII, of the Social Security Act. 50:These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N237: Incomplete/Invalid patient medical record for this service.
GBB06 The documentation submitted was for the incorrect date of service. Refer to
Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
   
GBB07 The documentation submitted does not support the modifiers billed. Refer to Medicare Program Integrity Manual Chapter 3, IOM Pub 100-04, Medicare Claims Processing Manual Chapter 1    
GBB09 The documentation submitted was for the incorrect beneficiary. Refer to IOM,Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8    
GBB11 The documentation submitted does not support the number of units billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23    
GBD15 The documentation contains conflicting information. Refer to Medicare Program Integrity Manual Chapter 4.3    
Missing or NO RUN report received NORUN Documentation received lacks the necessary Run Report GBB01 The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N237: Incomplete/Invalid patient medical record for this service. N109: This claim was chosen for complex review.
GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C    
Documentation Submitted Lacks the Necessary Treatment Time Component NOTIM Documentation received lacks the necessary time component. GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N443: Missing/incomplete/invalid total time or begin/end time
No or partial documentation received: Chief Complaint Not DOocumented in the medical record. CCNDO Documentation requested for this date of service was not received or was incomplete. GBB01 The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N29: Missing documentation/orders/notes/summary/report/chart N109: This claim was chosen for complex review
GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM,Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C    
No or partial documentation received: E and M Components Not Met (example: billed 99214 and documentation did not meet 2 out of 3 criteria). EMCNM Documentation requested for this date of service was not received or was incomplete. GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C 50:These are non-covered services because this is not deemed a "medical necessity" by the payer. N29: Missing documentation/orders/notes/summary/report/chart. N109: This claim was chosen for complex review
GBB03 The documentation submitted does not support services were rendered as billed. Refer to IOM-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A    
NO Chest X-Ray; no radiology report received NOCXR Documentation received lacks the necessary radiology report. GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. M31 - Missing radiology report.
Provider Signature Issues
Order Not SIGned ONSIG Order lacks the necessary provider signature. GBF01 The documentation submitted did not include a valid signature and/or credentials.
Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3,
Section 3.3.2.4 and CFR Part 482.24
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N456: Incomplete/invalid Physician Order. N109: This claim was chosen for complex review.
Invalid SIGNature ISIGN Information submitted contains an invalid/illegible provider signature. GBF01 The documentation submitted did not include a valid signature and/or credentials.
Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3,
Section 3.3.2.4 and CFR Part 482.24
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. MA81: Missing/Incomplete/Invalid provider/supplier signature N109: This claim was chosen for complex review.
GBF02 The documentation submitted did not include a valid signature and a response to
attestation or signature log request was not received. Refer to IOM, Medicare
Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4 and CFR Part
482.24
   
SIGnature STamp SIGST Documentation contains signature stamp. GBF03 Stamped signatures are not accepted. Refer to IOM, Medicare Program Integrity
Manual, Pub 100-08, Chapter 3, Section 3.3.2.4
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. MA81: Missing/Incomplete/Invalid provider/supplier signature. N109: This claim was chosen for complex review
NO SIGnature on documentation/progress notes NOSIG Documentation lacks the necessary provider signature. GBF01 The documentation submitted did not include a valid signature and/or credentials.
Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3,
Section 3.3.2.4 and CFR Part 482.24
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. MA81: Missing/Incomplete/Invalid provider/supplier signature N109: This claim was chosen for complex review
GBF02 The documentation submitted did not include a valid signature and a response to
attestation or signature log request was not received. Refer to IOM, Medicare
Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4 and CFR Part
482.24
   
Invalid signature:
Documentation Not Signed by the Rendering Provider.
DNSRP Information submitted contains an invalid/illegible provider signature. GBD18 The documentation submitted supports the performing and billing providers are
different.
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. MA81: Missing/Incomplete/Invalid provider/supplier signature. N109: This claim was chosen for complex review.
Invalid signature:
NP/NPP signed but MD billed and "Incident To" Requirements Not Met.
ITRNM Information submitted contains an invalid/illegible provider signature. GBF02 The documentation submitted did not include a valid signature and a response to
attestation or signature log request was not received. Refer to IOM, Medicare
Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4 and CFR Part
482.24
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. MA81: Missing/Incomplete/Invalid provider/supplier signature. N109: This claim was chosen for complex review
NO CReDentials documented for provider NOCRD Provider signature does not include the necessary provider credentials. GBF01 The documentation submitted did not include a valid signature and/or credentials. Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4 and CFR Part 482.24 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. MA81: Missing/Incomplete/Invalid provider/supplier signature. N109: This claim was chosen for complex review.
Beneficiary Signature Issues
Lack or Absence of a Beneficiary Signature BNSIG Documentation received lacks the necessary beneficiary or authorized representative signature. GBB02 The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. MA75: Missing/incomplete/invalid patient or authorized representative signature
Miscellaneous
ALTered Medical Records ALTMR Original medical record has been altered. GBD13 The documentation submitted contains cloned or altered information. Refer to Pub 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5; Chapter 4.3 50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N237: Incomplete/Invalid patient medical record for this service. N109: This claim was chosen for complex review.
Another provider already reimbursed for services DNOTH Services deemed payable to another provider. GBA02 This is a duplicate service previously submitted by a different provider. Refer to
IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 1 section 120-
120.3
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review. N472: Payment for this service has been issued to another provider
Not covered by Part B (billed global or only TC) in POS 21, 22 or 23 NOPRB Services not covered by Part B Medicare. GBD17 The service billed is statutorily excluded. Refer to Medicare Claims Processing Manual Chapter 30, Section 20.1.1, Social Security Act 1862 (a), 12 CFR 411.15, Medicare Benefit Policy Manual Chapter 16 109: Claim/Service not covered by this payer/contractor.  
GBC03 The service billed is not a covered Medicare benefit or is an excluded service. Refer to 42 CFR 411.15. Medicare Benefit Policy Manual Chapter 16; CFR title 42, Chapter IV, subchapter B, part 411    
Down Code        
Level of service should be Down Coded DWNCD Service is approved at a reduced level GBE01 The documentation submitted does not support the medical necessity of the level
of service billed. Refer to IOM, 100-08, Medicare Program Integrity Manual
Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing
Manual Chapter 23
50: These are non-covered services because this is not deemed a "medical necessity" by the payer. N109: This claim was chosen for complex review.
GBE02 The documentation submitted does not support the level of service billed. Refer to
IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.4
   

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