(Medicare Claims Processing Manual)

Contractors shall deny the CWF rejected claim if a new G -code is received for the same date of service as a previous claim was paid for the same line item date of service.   NOTE: The provider should submit an adjustment to the original claim to receive the higher payment.     Contractors shall use the following CARC/RARC codes when denying claims:   CARC 97 -  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N111 -  No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.   Claim Adjustment Group Code -  CO (Contractual Obligation)   MSN message: 41.14: This service/item was billed incorrectly. 41.14-  Este servicio o artculo fue facturado incorrectamente.   Contractors shall deny the CWF rejected G -code line when the claim has recycled three times without finding the associated drug J -code claim and use the following messages:   CARC 16 -  Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or R emittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N657 -  This should be billed with the appropriate code for these services. Claim Adjustment Group Code -  CO (Contractual Obligation)   MSN message: 41.14: This service/item was billed incorrectly. 41.14-  Este servicio o artculo fue facturado incorrectamente.   Contractors shall deny CWF rejected claims for more than one claim line service of G0088, G0089, or G0090 within a 60 day period and use the following messages:   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 N640 -  Exceeds number/frequency approved/allowed within time period.  Group Code -  CO (Contractual Obligation)   411.6  CWF and MCS Editing Requirements  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021, Implementation: 01- 04-2021)   MCS shall create a new edit to identify when there is more than one of the following six HCPCS G0068, G0069 G0070, G0088, G0089, or G0090 with Date of Service on or after 1/1/2021 for the same Date of Service on the same Part B Professional cla im.  CWF shall create a new reject for a Part B Professional claim with one of the following six HCPCS codes G0068, G0069 G0070, G0088, G0089, or G0090 with Date of Service on or after 1/1/2021 and there is no DME claim in history with one of the identified J-codes within 30 days prior to the incoming Date of Service.   NOTE :  This edit shall have override capability at the claim detail line   CWF and contractors shall recycle G0068, G0069 G0070, G0088, G0089, or G0090 claim up to three times for a total of 15 days until a claim containing an allowable drug J -code from above is received with the same line item date of service or with in 30 days prior to the line item date of service of the G -code.   CWF shall create a new reject for a Part B Professional claim with one of the following six G0068, G0069 G0070, G0088, G0089, or G0090 codes with a Date of Service on or after 1/1/2021 when there is a Part B claim in history with one of the ide ntified six G0068, G0069 G0070, G0088, G0089, or G0090 codes for the same Date of Service.   NOTE :  This edit shall have override capability at the claim detail line   CWF shall create a new reject for a Part B Professional claim with one of the new G0088, G0089, or G0090 codes and in history is an allowed DME or Part B Professional claim with any of the six G0068, G0069 G0070, G0088, G0089, or G0090  codes and the Dates of Service is within 60 days prior to the incoming claims Dates of Service. The incoming claim has Dates of Service on or after 1/1/2021.   CWF should still subject an incoming Part B Professional claim to the edit if it is within 60 days of posted DME claim, and if the claim in history is DME and has one of the three existing G0068, G0069 G0070  codes and has Dates of Service prior to 1/1/2021.  CWF shall create a new Informational Unsolicited Response (IUR) when a Part B Professional claim or a DME claim with one of the six G0068, G0069 G0070, G0088, G0089, or G0090  codes is received and in history is a Part B Professional claim with one of the three new G0088, G0089, or G0090 codes with Dates of Service within 60 days after the incoming claims Dates of Service.   CWF shall ensure that all new edits and the IUR appear on the ORPN Report.                Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12533CP  03/07/2024  Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 90 for Coding Revisions to the National Coverage Determinations (NCDs) --July 2024 Change Request (CR) 13507.  04/08/2024  13545  R12497CP  02/08/2024  Pulmonary Rehabilitation, Cardiac Rehabilitation and Intensive Cardiac Rehabilitation (PR/CR/ICR) Expansion of Supervising Practitioners  03/12/2024  13513  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  12435  R12396CP  12/07/2023  Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32 Sections 320.3.3 and 370.1 for Coding Revisions to the National Coverage Determinations (NCDs) --April 2024 Change Request (CR) 13390  01/09/2024  13438  R12109CP  06/29/2023  Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32 Sections 130.1, for International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) --October 2023 Update Change Request (CR) 13166   10/02/2023  13227  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  13104  R11875CP  02/23/2023  National Coverage Determination (NCD) 50.3 - Cochlear Implantation Manual Update  03/24/2023  13073  Rev #  Issue Date  Subject  Impl Date  CR#  R11789CP  01/19/2023  Update to the Internet Only Manual (IOM) For Alpha-Numerical Order in Publication (Pub.) 100-04, Chapter 32, Index, Sections 40.2.1 and 40.2.4  02/21/2023  13025  R11759CP  12/21/2022  Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 18 Section 170.1 and Chapter 32 Section 270.2 due to the National Coverage Determinations (NCDs) April 2023 Change Request (CR) 12960  01/23/2023  12993  R11721CP  11/28/2022  National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy  01/03/2023  12928  R11430CP  05/24/2022  Update to 'J' Drug Code List for Billing Home Infusion Therapy (HIT) Services  07/05/2022  12667  R11426CP   05/20/2022  An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage- Rescinded and replaced by transmittal 11426  07/05/2022  12613  R11272CP  02/18/2022  An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage