February 2007
Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Part A/B Medicare Administrative Contractors (A/B MACs), Durable Medical Equipment Regional Carriers (DMERCs) and DME Medicare Administrative Contractors (DME MACs)) for services.
Provider Action Needed
CR 5346, from which this article is taken, announces the latest update of X12N 835 Health Care Remittance Advice Remark Codes and X12N 835 and 837 Health Care Claim Adjustment Reason Codes, effective January 2, 2007. Be sure billing staff are aware of these changes.
Background
Two code sets—the reason and remark code sets—must be used to report payment adjustments in remittance advice transactions. The reason codes are also used in some coordination-of-benefits transactions.
The remittance advice remark code list is maintained by the Centers for Medicare & Medicaid Service (CMS), and used by all payers; and additions, deactivations, and modifications to it may be initiated by both Medicare and non-Medicare entities. The health care claim adjustment reason code list is maintained by a national Code Maintenance committee that meets when X12 meets for their trimester meetings to make decisions about additions, modifications, and retirement of existing reason codes.
Both code lists are updated three times a year, and are posted at http://wpc-edi.com/codes. The lists at the end of this article summarize the latest changes to these lists, as announced in CR 5346, effective on and after January 1, 2007.
CMS has also developed a new tool to help you search for a specific category of code and that tool is at http://www.cmsremarkcodes.info. Note that this website does not replace the WPC site and, should there be any discrepancies between this site and the WPC site, consider the WPC site to be correct.
Additional Information
You can see the official instruction issued to your FI/carrier/DMERC/RHHI regarding these latest remittance advice remark code and claim adjustment reason code updates by going to CR 5346, located at http://www.cms.hhs.gov/Transmittals/downloads/R1087CP.pdf on the CMS website.
For additional information about Remittance Advice, please refer to Understanding the Remittance Advice (RA): A Guide for Medicare Providers, Physicians, Suppliers, and Billers at http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the CMS website.
| Code | New/ Modified/ Deactivated/ Retired | Current Narrative | Comment |
|---|---|---|---|
| N370 | New | Billing exceeds the rental months covered/approved by the payer. | Medicare initiated |
| N371 | New | Alert: title of this equipment must be transferred to the patient. * | Medicare initiated |
| N372 | New | Only reasonable and necessary maintenance/service charges are covered. | Medicare initiated |
| MA02 | Modified | If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice. | Modified effective 8/1/06 |
| M114 | Modified | This service was processed in accordance with rules and guidelines under the Competitive Bidding Demonstration Project. If you would like more information regarding this project, contact your local contractor. | Modified effective 8/1/06 |
| N199 | Modified | Additional payment/recoupment approved based on payer-initiated review/audit. | Modified effective 8/1/06 |
| There are no deactivated remittance advice remark code changes | |||
*NOTE: Some remark codes may provide only information. They may not necessarily supplement the explanation provided through a reason code, or, in some cases another/other remark code(s), for an adjustment. Newly created informational codes will have “Alert” in the text to identify them as informational rather than explanatory codes. For example, this informational code is sent per state regulation, but does not explain any adjustment:
N369 Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
These informational codes will be used only if specific information needs to be communicated but not as default codes.
| Code | New/ Modified/ Deactivated/ Retired | Current Narrative | Comment |
|---|---|---|---|
| 196 | New | Claim/service denied based on prior payer's coverage determination | New as of June, 2006 |
| 16 | Modified | Claim/service lacks information, which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) | Modified as of February, 2002 and June, 2006 |
| 17 | Modified | Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) | Modified as of February, 2002 and June, 2006 |
| 96 | Modified | Non-covered charge(s). This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) | Modified as of February, 2002 and June, 2006 |
| 125 | Modified | Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) | Modified as of February, 2002 and June, 2006 |
| 43 | Retired | Gramm-Rudman reduction. | Modified as of June, 06, and deactivated on July 1, 2006 |
If you have any questions, please contact your state's Provider Contact Center.
MLN Matters MM5346