(Medicare Claims Processing Manual)

Effective for claims with dates of service on and after February 5, 2015, providers may also use the following TOBs when submitting claims for LDCT lung cancer screening, HCPCS code G0296:  71X, 77X, and 85X with revenue code 096X, 097X, and 098X.   The service shall be paid on the basis shown below:    Outpatient hospital departments -  TOBs 12X and 13X -  based on Outpatient Prospective Payment System (OPPS),    Skilled nursing facilities (SNFs) -  TOBs 22X and 23X -  based on the Medicare Physician Fee Schedule (MPFS),    -Critical Access Hospitals (CAHs) -  TOB 85X -  based on reasonable cost,   -CAH Method II -  TOB 85X with revenue code 096X, 097X, or 098X based on the lesser of the actual charge or the MPFS (115% of the lesser of the fee schedule amount and submitted charge) for HCPCS code G0296 only,    -Rural Health Clinics (RHCs) -  TOB 71X -  based on the all -inclusive rate for HCPCS G0296 only, and    -Federally Qualified Health Centers (FQHCs) - TOB 77X -  based on the prospective payment systems (PPS) rate for HCPCS G0296 only.  NOTE:  For outpatient hospital settings, as in any other setting, services covered under this NCD must be ordered and performed by eligible Medicare providers for these services that meet the eligibility and coverage requirements of this NCD.  See Pub.100- 03, Med icare NCD Manual, Chapter 1, Section 210.14, for complete coverage requirements.   220.3 - Deductible and Coinsurance  (Rev. 3374, Issued: 10-15-15 , Effective: 02 -05-15, Implementation: 01- 04-16)  There is no deductible and no coinsurance for HCPCS codes G0296 and G0297 claim lines.  220.4  Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev 11388, Issued:04- 29, 22; (Effective:02 -10-22; Implementation:10 -03-22)   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 LDCT lung cancer screening services, HCPCS codes G0296 and 71271:    Denying services  submitted on a TOB other than 12X, 13X, 22X, 23X, 71X, 77X, 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 and MSN 8.81. NOTE : Effective December 31, 2020, HCPCS code G0297 is end- dated and replaced with 71271.   Denying services for HCPCS G0296 for TOBs 71X and 77X when G0296 is billed on the same date of service with another visit (this does not apply to initial preventive physical exams for 71X TOBs), for claims with dates of service on and after February 5, 2015:   CARC 97 -  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if pre sent.   RARC M15 -  Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.   MSN 16.34 -  You should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the You May Be Billed column.   NOTE:  77X TOBs will be processed through the Integrated Outpatient Code Editor under the current process.   Group Code CO assigning financial liability to the provider.    Denying services where a previous HCPCS G0297 (effective January 1, 2021, G0297 is replaced with 71271), is paid in history in a 12-month period (at least 11 full months must elapse from the date of the last screening), for claims with dates of service on and after February 5, 2015:   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 policy was used when we made this decision: NCD 210.14.   Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 210.14.   Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:   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-MEDICAR E (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.   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).   NOTE:  For modifier GZ, use CARC 50 and MSN 8.81.   Denying claim lines for HCPCS G0296 and 71271 because the beneficiary is not between the ages of 50 and 77 (55 and 77 for DOS prior to February 10, 2022) at the time the service was rendered:               NOTE : Effective December 31, 2020 HCPCS code G0297 is end- dated and replaced with 71271.  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.   MSN 15.20: The following policy was used when we made this decision: NCD 210.14.  Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 210.14.   Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:   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-MEDICAR E (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 piensa 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.   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 for  HCPCS G0296 and 71271 because the claim line was not billed with  ICD -10 codes Z87.891(personal history of tobacco use/personal history of nicotine dependence), F17.210 (Nicotine dependence, cigarettes, uncomplicated ), F17.211 (Ni cotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine -induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicoti ne-induced disorders), effective with dates of service on or after October 1, 2015.              NOTE : Effective December 31, 2020, HCPCS code G0297 is end- dated and replaced with 71271. 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.  MSN 15.20  The following policy was used when we made this decision:  NCD 210.14.  Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 210.14.   Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:   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-MEDICAR E (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 piensa 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.   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).    NOTE:  For modifier GZ, use CARC 50 and MSN 8.81.         220.5  Common Working File (CWF) Edits  (Rev. 11388, Issued:04- 29, 22; (Effective:02 -10-22; Implementation:10 -03-22)   The common working file (CWF) shall apply the following limitations to lung cancer screening with LDCT:   Allow one HCPCS code 71271 per annum. At least 11 full months must elapse from the date of the last screening. NOTE:   This edit shall be overridable.