(Medicare Claims Processing Manual)

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.   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 [insert LMRP/LCD ID #(s) and NCD #(s)] were used when we made this decision.  Spanish Version - Las siguientes polticas [aadir los #s de LMRP/LCD, por sus siglas en ingls y los #s de NCD, por sus siglas en ingls] fueron utilizadas cuando se tom esta decisin.   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, Group Code CO, and MSN 8.81.   NOTE: This edit shall be overridable.    Denying services for HCV screening, G0472, for beneficiaries who do not meet the definition of high risk, but who were born from 1945 through 1965, when claims are submitted more than once in a  lifetime:  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 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, Group Code CO, and MSN 8.81.   NOTE: This edit shall be overridable.    Denying claim lines for HCV screening, G0472, without the appropriate POS  code:  CARC 171  Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N428 -  Not covered when performed in certain settings.  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 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 claim lines for HCV screening, G0472, that are not submitted from the appropriate provider  specialties:  CARC 184 -  The prescribing/ordering provider is not eligible to prescribe/order the service billed. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N574  Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.   MSN 21.18 -  This item or service is not covered when performed or ordered by this provider.   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, Group Code CO, and MSN 8.81.    Denying claim lines for HCV screening, HCPCS G0472, if beneficiary born prior to 1945 and after 1965 who are not at high risk (absence of ICD -10 diagnosis code Z72.89 or F19.20 or Z11.59:   CARC 96 -  Non -covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segme nt (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 15.19 -  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).   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.  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).   210.4 - Common Working File (CWF) Edits  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  The common working file (CWF) shall apply the following frequency limitations to HCV screening, HCPCS G0472:   One initial HCV screening, HCPCS G0472, for beneficiaries at high risk, when claims are submitted with ICD-9 diagnosis code V69.8/ICD -10 diagnosis code Z72.89 (once ICD -10 is implemented),   Annual HCV screening, HCPCS G0472, when claims are submitted with ICD -9 diagnosis code V69.8/ICD -10 diagnosis code Z72.89 (once ICD -10 is implemented), and ICD -9 diagnosis code 304.91/ICD -10 diagnosis code F19.20 (once ICD -10 is implemented),   Once in a lifetime HCV screening, HCPCS G0472, for beneficiaries who are not high risk who were born from 1945 through 1965.   NOTE: These edits shall be overridable.   NOTE: HCV screening, HCPCS G0472 is not a covered service for beneficiaries born prior to 1945 and after 1965 who are not at high risk (absence of ICD -10 diagnosis code Z72.89 and/or F19.20 and/or Z11.59 ICD-10 diagnosis code.   220 - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)  (Rev. 3374, Issued: 10-15-15 , Effective: 02 -05-15, Implementation: 01- 04-16)  Effective for services furnished on or after February 5, 2015, Medicare covers a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT) if all the eligibility requirements listed in the national coverage determination (NCD) are met.   See Pub.100- 03, Medicare NCD Manual, Chapter 1, Section 210.14, for complete coverage requirements.  220.1 - Health Care Common Procedure Coding System (HCPCS) Codes  (Rev. 3374, Issued: 10-15-15 , Effective: 02 -05-15, Implementation: 01- 04-16)  Effective for claims with dates of service on and after February 5, 2015, the following codes are used for lung cancer screening with LDCT services:   G0296 -  Counseling visit to discuss need for  lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)   G0297 -  Low dose CT scan (LDCT) for lung cancer screening  220.2 - Institutional Billing Requirements  (Rev. 3374, Issued: 10-15-15 , Effective: 02 -05-15, Implementation: 01- 04-16)  Effective for claims with dates of service on and after February 5, 2015, providers may use the following types of bill (TOBs) when submitting claims for LDCT lung cancer screening, HCPCS codes G0296 and G0297:  12X, 13X, 22X, 23X, and 85X.   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