(Medicare Claims Processing Manual)

130.1.2 - Claim Change Reasons  (Rev. 1, 10- 01-03) HO- 411.2, HO -IM411.2, HH -445  130.1.2.1 - Claim Change Reason Codes  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The provider submits one of the following claim change reason codes to its FI with each debit -only or cancel -only adjustment request:   Bill Type  Reason Code  Explanation  Xx7 D0 (zero)  Change to service dates  Xx7 D1 Change in charges  Xx7 D2 Change in revenue codes/HCPCS - HIPPS  Xx7 D3 Second or subsequent interim PPS bill - PPS inpatient hospital only  Xx7 D4 Change in GROUPER input (diagnoses or procedures) - PPS inpatient hospital).  Xx8 D5 Cancel -only to correct a Medicare beneficiary identifier or provider identification number  Xx8 D6 Cancel -only to repay a duplicate payment or OIG overpayment (includes cancellation of an outpatient bill containing services required to be included on the inpatient bill.)  Xx7 D7 Change to make Medicare the secondary payer  Xx7 D8 Change to make Medicare the primary payer  Xx7 D9 Any other change  Xx7 E0 (zero)  Change in patient status   The provider may not submit more than one claim change reason code per adjustment request.  It must choose the single reason that best describes the adjustment it is requesting.  It should use claim change reason code D1 only when the charges are the only change on the claim.  Other claim change reasons frequently change charges, but the provider may not add reason code D1 when this occurs.   The claim change reason code is entered as a condition code on the hard copy Form CMS -1450 or the electronic equivalent.  For reason codes D0- D4 and D7- D9, the biller submits a debit -only adjustment request, bill type xx7.  For reason codes D5 and D6, it submits a cancel -only adjustment request, bill type xx8.  130.1.2.2 - Edits on Claim Change Reason Codes  (Rev. 1, 10- 01-03) The following edits are based on the claim change reason code.  The FI must apply them to each incoming adjustment request.   If the type of bill is equal to xx7 and the claim change reason code is not equal to D0-D4, D7 -D9, or E0, the FI rejects the request back to the provider with the following error message, Claim change reason code must be present and equal to D0-D4, D7 -D9, or E0 for a debit -only adjustment request.   If the type of bill is equal to xx8 and the claim change reason code is not equal to D5-D6, the FI rejects the request back to the provider with the following error message, Claim change reason code must be present and equal to D5 -D6 for a cancel -only adj ustment request.   If the type of bill is equal to xx7 or xx8 and the ICN/DCN of the claim being adjusted is not present, the FI rejects the request back to the provider with the following message,  ICN/DCN of the claim being adjusted is required for an adjustment request.   If more than one claim change reason code is present on the providers request, the FI rejects the request back to the provider with the following message; only one claim change reason code may apply to a single adjustment request from a provider.  The FI  chooses the single claim change reason code that best describes the reason for the providers request and resubmit.   If the provider submits an adjustment request as type of bill not equal to xx7 or xx8, the FI rejects the request back to the provider with the message, Provider submitted adjustment request must use type of bill equal to xx7 or xx8.   If the claim change reason code is equal to D0, the FI compares the beginning and ending dates on the providers request to those on the claim to be adjusted on its history.  If these dates are the same, it rejects the request back to the provider with the message, Dates of service must change for claim change reason code D0.   If the claim change reason code is equal to D1, the FI compares the total and line item charges on the providers request to those on the claim to be adjusted on its history.  If these changes are the same, the FI rejects the request back to the provider w ith the message, Charges must be changed for claim change reason code D1.   If the claim change reason code is equal to D2 (revenue code/HCPCS or HIPPS), the FI compares revenue codes/HCPCS or HIPPS on the providers request to those on the claim to be adjusted on its history.  If these codes are the same, it rejects the request b ack to the provider with the message, Revenue codes/HCPCS or HIPPS must change for claim change reason code D2.   If the claim change reason code is equal to D3 (PPS inpatient hospital only), the FI compares the ending date on the hospitals request to that on the claim to be adjusted on its history.  If these dates are the same, it rejects the request back to the hos pital with the message, Thru dates must change for the claim change reason code D3.   If the claim change reason code is equal to D4 (PPS inpatient hospital), the FI compares diagnosis and procedure codes on the providers request to those on the claim to be adjusted on its history.  If these codes are the same and are in the same sequence,  it rejects the request back to the provider with the message, Diagnoses and/or procedures must change for claim change reason code D4.   If the claim change reason code is equal to D5 or D6, type of bill must be equal to xx8 on the providers request.  If type of bill is not equal to xx8, the FI rejects the request back to the provider with the message, Type of bill must be equal to xx8 for claim change reason codes D5 or D6.   If the claim change reason code is equal to D7, an MSP value code (12 -16, 41- 43, or 47) must be present, if a value code, 12- 16, 41- 43, or 47, is not present, the FI rejects the request back to the provider with the message, An MSP value code (12-16, 41- 43, or 47) must be present for claim change reason code D7.   If the claim change reason code is equal to D7, and one or more of value codes 12-16, 41- 43, and/or 47 is present but each value amount is equal to 0 (zero) or spaces, the FI rejects the request back to the provider with the message, invalid value amount for claim change reason code D7.   If the claim change reason code is equal to D8, and a value code 12 -16, 41- 43, or 47 is present, the FI rejects the claim back to the provider with the message, Invalid value code for claim change reason D8.   If the claim change reason code is equal to E0, the FI compares patient status on the providers request to that on the claim to be adjusted.  If patient status is the same, the FI rejects the request back to the provider with the message, Patient status must change for claim change reason E0.  The FI must suspend for investigation all adjustment requests with claim change reason codes D8, and D9.  Providers that consistently use D9 will be investigated and, if a pattern of abuse is evident, may be reported to the OIG.   130.1.2.3 - Additional Edits  (Rev. 1, 10- 01-03) The FI must perform the following additional edits and investigate adjustment requests the provider submits:   A full denial once the bill is paid, except to accomplish retraction of a duplicate payment;   Inpatient Hospital Only -  A change in DRG based on a change in age or sex;   A change in deductible;   An adjustment request that changes a previously submitted QIO adjustment request;   An adjustment of a bill due to a change in utilization or spell data on another bill;   A reopening to change a no- payment bill to a payment bill;   A reopening to pay a previously denied line item;   An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or   An adjustment request with a claim change reason code equal to E0, and the claim is for an inpatient PPS hospital.  The FI must investigate if the change is from patient status 02, transferred to another acute care facility.  130.1.3 - Late Charges  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.