(Medicare Claims Processing Manual)

NOTE: Due to system requirement, the Fiscal Intermediary Standard System (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.  G. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based  Biomarker  test (HCPCS  G0327)  because  the beneficiary  is not between  the ages of 45 and 85, use:  15.19 - We used a Local  Coverage  Determination  (LCD) to decide coverage for your  claim.  To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage- database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura  de su reclamo.  Para apelar,  obtenga  una copia  del LCD  en www.cms.gov/medicare - coverage- database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  15.20 - The following policies NCD  210.3 were  used when we  made this decision.  Spanish Version   Las  siguientes  polticas  NCD 210.3 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.  H. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based Biomarker test (HCPCS G0327) because the claim does not contain all of the ICD-10 diagnosis codes required, use:   15.19 - We used a Local  Coverage  Determination  (LCD) to decide coverage for your  claim.  To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage- database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura  de su reclamo.  Para apelar,  obtenga  una copia  del LCD  en www.cms.gov/medicare - coverage- database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  15.20 - The following policies  210.3 were  used  when we  made this decision  Spanish Version   Las  siguientes  polticas  NCD210.3 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.  I. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based Biomarker test (HCPCS G0327) on institutional claims when submitted on a TOB other than 13X, 14X, and 85X, use:   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."   60.8 - Remittance Advice Codes (Rev. 12299; Issued:10 -12-23; Effective:01 -01-23; Implementation:11 -13-23) All messages  refer  to ANSI  X12N  835 coding.  A. If the claim  for a screening  FOBT, a  screening  flexible  sigmoidoscopy, or a screening barium enema is being denied because the patient is less than 45 years of age, use:  Claim Adjustment  Reason  Code  (CARC)  6 The procedure/revenue code  is inconsistent  with the patients age, at the line level; and, Remittance Advice Remark Code (RARC)  N129 Not eligible due to patients age  B. If the claim for a screening FOBT, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening  barium  enema is being denied  because the time period between the test/procedure has not passed, use:   CARC 119 Benefit  maximum for this time period or occurrence has been  reached at  the line level.  C. If the claim  is being denied  for a screening  colonoscopy (HCPCS  G0105)  or a screening barium enema (HCPCS G0120) because the patient is not at a high risk, use:   CARC 46 This  (these) service(s)  is (are)  not covered at  the line level;  and,   RARC M83 Service is not covered  unless  the patient  is classified  as a high risk.  at the line level.   D. If the service is being denied  because payment  has already  been  made for a similar procedure within the set time frame, use:   CARC 18, Duplicate claim/service  at the line level; and,    RARC M86 Service is denied  because payment  already  made for similar  procedure  within  a set timeframe. at the line level.   E. If the claim  is being denied  for a non-covered  screening procedure  such as HCPCS  G0122, use: CARC 49, These are non-covered  services  because this is a routine  exam  or screening procedure done in conjunction with a routine exam.   F. If the claim  is being denied  because  the code is invalid, use  the following at the line level:   CARC B18 Payment  denied because  this procedure  code/modifier  was invalid  on the date of service or claim submission.  G. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT  81528) or Blood- based Biomarker test (HCPCS G0327) when furnished more than once in a 3- year period [at least 2 years and  11 full months  (35 months  total)  must  elapse from  the date of the last screening], use:    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.   Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.   H. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528) or Blood- based  Biomarker  test (HCPCS  G0327)  when  beneficiary  is not between  the ages  45-85, use:   CARC 6:  The procedure/revenue code  is inconsistent  with  the patient's  age. Note:  Refer  to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    RARC N129:  Not  eligible  due to the patients  age.   Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.   I. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based Biomarker test (HCPCS G0327) when the claim does not contain ICD-10 diagnosis codes Z12.12 OR Z12.11), use:   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.  Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.  J. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528) or  Blood- based  Biomarker  test (HCPCS  G0327)  when  claims  are submitted  on a TOB  other  than 13X, 14X, or 85X, use:   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.  Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.  70 - Glaucoma Screening Services  (Rev. 1, 10- 01-03)  B3-4184  Conditions of Medicare Part B coverage for glaucoma screening are located in the Medicare Benefit Policy Manual, Chapter 15.    70.1 - Claims Submission Requirements and Applicable HCPCS Codes  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  70.1.1 - HCPCS and Diagnosis Coding  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  The following HCPCS codes should be reported when billing for screening glaucoma services:   G0117 -  Glaucoma screening for high- risk patients furnished by an optometrist (physician for A/B MAC (B)) or ophthalmologist.   G0118 -  Glaucoma screening for high- risk patients furnished under the direct supervision of an optometrist (physician for A/B MAC (B) or ophthalmologist.   The A/B MAC (B) claims type of service for the above G codes is: TOS Q.   Glaucoma screening claims should be billed using screening (V) code V80.1 (Special Screening for Neurological, Eye, and Ear Diseases, Glaucoma), or if ICD -10-CM is applicable, diagnosis code Z13.5 (encounter for screening for eye and ear disorders).  Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable (refer to chapter 1 of this manual for more information about incomplete or invalid claims).   70.1.1.1 - Additional Coding Applicable to Claims Submitted to A/B MACs (A)  (Rev. 371, Issued 11- 19-04, Effective: 04 -01-05, Implementation: 04- 04-05)  A. Type of Bill