(Medicare Claims Processing Manual)

Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a  claim  line-item 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 services where previous HBV screening, HCPCS 86704, 86706, 87340 or 87341, is paid during the same pregnancy period or more than two screenings are paid to women that are  at high risk:   CARC 119:  Benefit  maximum for this time  period or  occurrence has been  reached.   RARC N362: The number of days or units of service exceeds our acceptable  maximum.   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 on the CMS  website. 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. 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 piensa  que puede cambiar  nuestra  decisin. Para obtener  una copia  del LCD,  llame  al 1-800-MEDICARE  (1-800-633-4227).   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  and occurrence code  32 is not present)   Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a  claim is received with occurrence code 32 with or without a GZ modifier indicating no signed ABN is on file).   b. Denying services for HBV screening, HCPCS G0499, when ICD -10 diagnosis code  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, or  O09.93 is present  on the  claim:  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 (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 piensa  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 210.6 were used when we made this  decision. Spanish Version  Las siguientes polticas NCD 210.6 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.    Denying claim lines for HBV screening, HCPCS G0499 for a subsequent HBV  screening  test for non-pregnant, high risk  beneficiary  when  a claim  line for an  initial HBV screening  has not  yet been posted in history:   CARC B15  This service/procedure requires that a qualifying service/procedure be  received and covered. The qualifying other service/procedure has not been  received/adjudicated. 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 (Contractual  Obligation).  MSN  21.21:  This  service was  denied  because Medicare only covers  this service under  certain  circumstances.  Spanish Version  - Este servicio  fue denegado  porque  Medicare solamente lo cubre  bajo ciertas  circunstancias.   (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 piensa  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 210.6 were used when we made this  decision.  Spanish Version  Las siguientes polticas NCD 210.6 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   240 - Prolonged Preventive Services Codes  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18)  Effective for claims with dates of service on or after January 1, 2018, prolonged preventive services (PPS) may be reported as an add- on to a covered preventive service that is payable from the Medicare Physician Fee Schedule.   PPS codes are treated as a preventive service and both coinsurance and deductible do not apply when billed with a covered preventive service which is part of a particular subset of procedure codes listed at https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/PhysicianFeeSched/Medicare- PFS-Preventive -Services.html   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Implementation Date  CR#  R12435CP  12/28/2023 Update to the Internet Only Manual (IOM) Publication (Pub.) 100- 04, Chapter 18, Sections 20.2, 60.3 and Chapter 32, Sections 50.4.1, 200.2 for Coding Revisions to the National Coverage Determinations (NCDs) --April 2024 Change Request (CR) 13391 01/29/2024 13461  R12299CP   10/12/2023 An Omnibus CR to Implement Policy Updates in the CY 2023 PFS Final Rule, Including (1) Removal of Selected NCDs (NCD 160.22 Ambulatory EEG Monitoring), and, (2) Expanding Coverage of Colorectal Cancer Screening -  Full Agile Pilot CR  11/13/2023 13017  R12070CP  06/07/2023 Internet Only Manual Update to Publication 100- 04, Chapters 9 and 18 to Clarify Vaccine Payment Instructions for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)  07/10/2023 13218  R11902CP  03/16/2023 Update to the Internet Only Manual (IOM) Publication (Pub.) 100- 04, Chapter 18 Sections 50.3- 50.4, and Chapter 32 Sections 130.1, 170.2 for Coding Revisions to National Coverage Determinations (NCDs) --July 2023 Change Request (CR) 13070 04/17/2023 10104  R11865CP  02/16/2023 An Omnibus CR to Implement Policy Updates in the CY 2023 PFS Final Rule, Including (1) Removal of Selected NCDs (NCD 160.22 Ambulatory EEG Monitoring), and, (2) Expanding Coverage of Colorectal Cancer Screening -  Full Agile Pilot CR  Rescinded and replaced by  Transmittal 02/27/2023 13017  Rev #  Issue Date  Subject  Implementation Date  CR#  12299