(Medicare Claims Processing Manual)

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.  MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.   Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file).  Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).  NOTE:  For modifier GZ, use CARC 50 and MSN 8.81.   Denying claim lines without the appropriate POS code:   CARC 5 -  The procedure code/bill type is inconsistent with the place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC M77 -  Missing/incomplete/invalid place of service.   MSN 21.25 -  This service was denied because Medicare only covers this service in certain settings.   Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).  NOTE:   For modifier GZ, use CARC 50 and MSN 8.81.   Denying claim lines that are not submitted from the appropriate provider specialties:   CARC 8 -  The procedure code is inconsistent with the provider type/specialty (taxonomy).  NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC  N95 -  This provider type/provider specialty may not bill this service.   MSN 21.18 -  This item or service is not covered when performed or ordered by this provider.   Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).  NOTE:   For modifier GZ, use CARC 50 and MSN 8.81.  200.5 - Common Working File (CWF) Edits  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  When applying frequency, CWF shall count 22 counseling sessions of any of G0473 and/or G0447 (for a total of no more than 22 sessions in the same 12- month period) along with 1 ICD -9-CM code from V85.30- V85.39 or V85.41- V85.45 in a 12- month period, or if IC D-10 is applicable with 1 ICD -10-CM code from Z68.30-Z68.39 or Z68.41- Z68.45.  When applying frequency limitations to G0473 or G0447 counseling CWF shall allow both a claim for the professional service and a claim for a facility fee.  CWF shall identify th e following institutional claims as facility fee claims for this service: TOB 13X, TOB 85X when the revenue code is not 096X, 097X, or 098X.  CWF shall identify all other claims as professional service claims.  210 - Screening for Hepatitis C Virus (HCV)  (Rev. 3215, Issued: 03 -11-15, Effective: 06 -02-14, Implementation: 01- 05-15 - For non -shared MAC edits and CWF analysis; 04- 06-15 - For remaining shared systems edits )  Effective for services furnished on or after June 2, 2014, Medicare covers screening for hepatitis C Virus (HCV) with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA -approved labeling and in compliance with the Clinical Laboratory Improvement Act regulations, when ordered by the beneficiarys primary care physician or practitioner within the context of a primary care setting, and performed by an eligible Medicare provider for these services , for beneficiaries who meet either of the following conditions:   A. Frequency   1. A single, one -time HCV screening test is covered for adults who are not considered high risk as defined below, but who were born from 1945 through 1965.  Those persons born prior to 1945 or after 1965 without high risk factors are not eligible for this benefit.   2. An initial screening for HCV is covered for adults at high risk for HCV infection regardless of birth year.  High risk is defined as persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992.   3. Repeat HCV screening for a sub -set of high risk persons regardless of birth year is covered annually only for persons who have had continued illicit injection drug use since the prior negative HCV screening test.   NOTE:  Annual means a full 11 months must elapse following the month in which the previous negative HCV screening took place.  B. Determination of High Risk for Hepatitis C Disease   The determination of high risk for HCV is identified by the primary care physician or practitioner who assesses the patients history, which is part of any complete medical history, typically part of an annual wellness visit, and considered in the development of a comprehensive prevention plan.  The medical record should be a reflection of the service provided.   NOTE:  See Pub. 100- 03, Medicare National Coverage Determinations (NCD) Manual, 210.13 for complete coverage guidelines.   NOTE:  Beneficiary coinsurance and deductibles do not apply to claim lines containing HCPCS G0472, hepatitis C antibody screening for individual at high risk and other covered indication(s).  NOTE:  A/B MACs (B) shall contractor -price HCV screening claims, HCPCS G0472, with dates of service June 2, 2014 through December 31, 2015.   210.1  Institutional Billing Requirements  (Rev. 3393, Issued: 11- 05-15, Effective: 06 -02-14, Implementation: 04- 04-16)  Effective for claims with dates of service on and after June 2, 2014, providers may use the following types of bill (TOBs) when submitting claims for screening for HCV screening, HCPCS G0472: 13X, 14X, and 85X. Service line- items on other TOBs shall be denied.   The service shall be paid on the basis shown below:    Outpatient hospitals  TOB 13X -  based on Outpatient Prospective Payment System (OPPS)   Non-patient laboratory specimen  TOB 14X  based on laboratory fee schedule   Critical Access Hospitals (CAHs) -  TOB 85X  based on reasonable cost   NOTE: For outpatient hospital settings, as in any other setting, services covered under this NCD must be ordered by a primary care provider within the context of a primary care setting and performed by an eligible Medicare provider for these services.   210.2 - Professional Billing Requirements  (Rev. 3215, Issued: 03- 11-15, Effective: 06 -02-14, Implementation: 01- 05-15 - For non -shared MAC edits and CWF analysis; 04- 06-15 - For remaining shared systems edits)   For claims with dates of service on or after June 2, 2014, Medicare will allow coverage for HCV screening, HCPCS G0472, only when services are ordered by the following provider specialties found on the providers enrollment record:   01 - General Practice  08 - Family Practice  11 - Internal Medicine  16 - Obstetrics/Gynecology 37 - Pediatric Medicine  38 - Geriatric Medicine  42 - Certified Nurse Midwife  50 - Nurse Practitioner  89 - Certified Clinical Nurse Specialist 97 - Physician Assistant   HCV screening services ordered by providers other than the specialty types noted above will be denied.  For claims with dates of service on or after June 2, 2014, Medicare will allow coverage for HCV screening, HCPCS G0472, only when submitted with one of the following place of service (POS) codes:   11 - Physicians Office  22 - Outpatient Hospital 49 - Independent Clinic  71 - State or Local Public Health Clinic  81 - Independent Laboratory  HCV screening claims submitted without one of the POS codes noted above will be denied.   210.3  Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for HCV screening, HCPCS G0472:    Denying services submitted on a TOB other than 13X, 14X, or  85X:   CARC 170 -  Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N95  This provider type/provider specialty may not bill this service.  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."   Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).  NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.   Denying services where previous HCV screening, HCPCS G0472, is paid in history for claims with dates of service on and after June 2, 2014, and the patient is not deemed high risk by the presence of ICD-10 diagnosis code Z72.89, other problems related to li festyle, and ICD -10 diagnosis code F19.20, other psychoactive substance dependence, uncomplicated:   CARC 119  Benefit maximum for this time period or occurrence has been reached.   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.  MSN 15.20  The following policies NCD210.13 were used when we made this decision.  Spanish Version  Las siguientes politicas NCD210.13 fueron utilizadas cuando se tomo esta decision.  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).  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.   NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.   NOTE: This edit shall be overridable.   Denying services for HCV screening, HCPCS G0472, for beneficiaries at high risk who have had continued illicit drug use since the prior negative screening test, when claims are not submitted with ICD-10 diagnosis code Z72.89, and ICD -10 diagnosis code F19.20, and/or 11 full months have not passed since the last negative HCV screening  test:  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.