(Medicare Claims Processing Manual)

Group Code CO   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  Ca ll 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).  MSN 15.20: The following policies NCD210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decision.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Effective for dates of service on or after April 13, 2015, when denying claims for CPT 80081 when submitted with one of the following secondary diagnosis codes denoting pregnancy, but the required HIV primary diagnosis codes listed below is not present:  For ICD -9: V22.0, V22.1, V23.9 For ICD -10: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83,Z34,90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, O09.93 Use the following denial messages:   CARC 167  This (these) diagnosis(es) is (are) not covered.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF),  if present.   RARC N386  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Cal l 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decisin.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code  CO    Effective for dates of service on or after April 13, 2015, when denying claims for HCPCS 80081when the line item is submitted with one of the following required HIV primary diagnosis codes:   For ICD-9: V73.89   For ICD -10: Z11.4   And none of the following secondary diagnosis codes denoting pregnancy are present.  For ICD -9: V22.0, V22.1, V23.9   For ICD -10: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83,  Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, O09.93  Use the following denial messages,   CARC 11:  This diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    RARC N386:  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web ac cess, you may contact the contractor to request a copy of the NCD.   Group Code: CO (Contractual Obligation)   (Part A only) MSN 15.19:  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.7 fueron utilizadas cuando se tom esta decisin.   NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.     Effective for dates of service on or after April 13, 2015, when denying line level claims for G0475, G0432, G0433, G0435 or the CPT code 80081 is submitted with one of the pregnancy secondary diagnosis codes, but the Sex Code on the claim indicates Male,  use the following denial messages:   CARC 7: The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   Group Code: CO (Contractual Obligation)   (Part A only) MSN 15.19:  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICARE (1 -800-+-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.7 fueron utilizadas cuando se tom esta decisin.   NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.     Effective for dates of service on or after April 13, 2015, when denying line -items with POS other than 11 (Office) or 81 (Independent Lab) for the HIV screenings HCPCS G0475, G0432, G0433 and G0435, use the following denial messages:   CARC 171  Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  RARC N428 -  Not covered when performed in certain settings.  Group Code: CO (Contractual Obligation)   MSN 21.25 -  This service was denied because Medicare only covers this service in certain settings.     Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   MSN 15.19:  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.7 fueron utilizadas cuando se tom esta decisin.   140 - Annual Wellness Visit (AWV)  (Rev. 2159, Issued: 02- 15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Pursuant to section 4103 of the Affordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) amended section 411.15(a)(1) and 411.15(k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage) effective fo r services furnished on or after January 1, 2011.  This expanded coverage is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS), for an individual who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months.  The AWV will include the establishment of, or update to, the individuals medical/family history, measurement of his/her height, weight, body- mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B.  CMS amended 42 CFR 411.15(a)(1) and 411.15(k)(15) to allow payment on or after January 1, 2011, for an AWV (as established at 42 CFR 410.15) when performed by qualified health professionals.  Coverage is available for an AWV that meets the following requirements:   1. It is performed by a health professional;   2. It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and he/she has not received either an IPPE or an AWV providing PPPS within the past 12 months.  See Pub. 100- 02,Medicare Benefit Policy Manual, chapter 15, section 280.5, for detailed policy regarding the AWV, including definitions of:  (1) detection of cognitive impairment, (2) eligible beneficiary, (3) establishment of, or an update to, an individuals medical/family history, (4&5) first and subsequent AWVs providing PPPS, (6) health professional, and, (7) review of an individuals functional ability/level of safety.