Changes between Initial Version and Version 1 of ExplanationCodes

Timestamp:

Jun 18, 2013, 9:47:37 AM (12 years ago)

Author:

Ray Richardson

Comment:

--

ExplanationCodes

@@ +1 @@
+= Explanation Codes =
+
+These codes are descriptive codes that identify what was done to the claim line and the denial explanation.
+
+codes in '''bold''' are considered most relevant for CCHCS 
+|| Code  || Description || Explanation ||
+||  04   || Expense not covered by plan || Return to CCIH if Code # 04 is seen by itself. MCOB Code, sometimes left on in error, denied for another reason. ||
+||  06   || Inmate not eligible || Sent back on Eligibility spreadsheet by CCHCS ||
+||  13   || PPO Benefits applied || Populates on all paid claims ||
+||  24   || Duplicate charge || May be one line or entire claim ||
+|| '''27'''   || '''Claim adjustment''' || Additional payment on a previously paid claim. Possibly when the wrong contract rate was used for first payment. ||
+||  32   || Paid by previous carrier ||  ||
+||  36   || Duplicate of a corrected claim || May be one line or entire claim ||
+|| '''40'''   || '''Additional payment''' || Used with Code 27 (e.g. Bill Type 137, or appeal received) ||
+||  42   || Inmate responsible for charges || Paroled inmate, CCIH does not send out EOB. Vendor must bill inmate. ||
+||  44   || Not covered, member responsible || Paroled inmate or charges for personal items ||
+||  45   || Re-file with physicians name || Physician's name is missing ||
+||  46   || Prior to effective date of group ||  ||
+||  47   || Submit itemized statement || Additional data required for inpatient bill ||
+||  48   || Inclusive with per Diem rate || Facilities with per diem rate; charge amount may be more than allowed ||
+||  50   || Submit entire medical record || Additional data required ||
+||  51   || Amount previously billed || Duplicate- a second claim requested differently for same DOS ||
+||  57   || Not a state inmate ||  ||
+||  65   || Late charges are not covered ||  ||
+||  67   || Other coverage primary ||  ||
+||  82   || Corrected EOB || EOB will not see; returned from CCHCS ||
+|| '''95'''   || '''Claim denial upheld''' || Vendor appeal- claim did not change ||
+||  96   || Inmate on medical furlough ||  ||
+||  107   || Corrected claim received ||  ||
+||  108   || Does not change amount paid || Used in conjunction with Denial Code # 95 ||
+||  114   || Cannot bill assistant surgeon charges || surgery is not qualified for an assistant surgeon per Medicare ||
+||  121   || Inmate paroled || On Eligibility information returned from CCHCS ||
+||  123   || Invalid CPT code- resubmit || Use of an older or not eligible code; must refile claim ||
+||  130   || Diagnosis not valid for sex ||  ||
+||  131   || Newborn care is not covered ||  ||
+||  137   || Included in case rate || Same as a bundled charge for services- Replacing Code # 165 ||
+||  139   || Included with DRG rate ||  ||
+||  146   || No allowance for modifier 26 || Charge is not allowed to be read usually for the 2nd time; Medicare guidelines ||
+||  150   || Convenience items not covered || Inpatient bill charges such as telephone or tv ||
+||  151   || After hours charges not covered || Used in conjunction with Medicare guidelines ||
+||  153   || Invalid age for CPT code || Used if billed incorrectly a CPT invalid for the age of patient ||
+||  154   || Invalid sex for CPT code ||  ||
+||  155   || Invalid place of service ||  ||
+||  156   || Invalid modifier code ||  ||
+||  157   || Invalid diagnosis code ||  ||
+||  158   || Invalid age for diagnosis ||  ||
+||  159   || Unacceptable primary diagnosis ||  ||
+||  160   || Incidental procedure || Part of bundled procedures; physician bill ||
+||  161   || Charge included in another code || Same as Code # 193 & 194 ||
+||  162   || CPT not valid for service date || Billing error; provider billed originally with an invalid code ||
+||  163   || Included in global time period || Same as Code # 204 & 137 ||
+||  164   || Possible catastrophe ||  ||
+||  165   || Included in global allowance || Multi-lined claim and amount all-inclusive; cannot allow additional monies; rebill if no monies paid originally ||
+||  166   || Not medically necessary ||  ||
+||  167   || Elective procedure not covered ||  ||
+||  168  || Cosmetic procedure non covered ||  ||        
+||  169  || Secondary Diagnosis required        ||  ||
+||  170  || Non specific Primary Diagnosis ||  ||        
+|| '''171''' || '''Invoice required for payment''' || Invoice required per contract for specific service (ex.blood, implant) ||
+||  172  || Claim paid by CCHCS || Duplicate; another claim received by CCIH that CCHCS has already paid ||
+||  173  || Resubmit Claim with DRG code || Missing DRG code ||
+||  174  || Not eligible ||  ||  
+||  177  || Page 1 of 2 missing, resubmit ||  ||         
+||  178  || Page 2 of 2 missing, resubmit ||  ||         
+||  179  || Submit additional documentation || e.g. Admin Dates ||
+||  184  || Resubmit claim by fiscal Year || Claim crossing two FYs ||
+||  186  || Claim returned to CCHCS || Regents, Alvarado Physician- any claims returned CCHCS ||
+||  187  || Multiple pages missing, re-bill ||  ||       
+||  188  || Resubmit with CPT code || Facility bills missing CPT codes with Revenue codes ||
+||  190  || No diagnosis code submitted ||  ||
+||  191  || Please resubmit with diagnosis ||  || 
+||  192  || Bill lacks required modifier/CPT code || Missing billing code, modifier or CPT for this line of service ||
+||  193 & 194 || Code is a component of another; not allowable  || Used together, with 3M pricing ||
+||  195 & 196 || Code not recognized by OPPS; alternate code available; re-bill    || Used together, with 3M pricing. ||
+||  197  || Resubmit Corrected Billing ||  ||    
+||  202  || CPT/Procedure code not allowable || 3M pricing, not allowed by Medicare. (e.g. 99053) ||
+||  203  || Invalid bill type; resubmit || Using an invalid Bill Type ||
+||  204  || Inclusive with Base Rate    || Same as Code # 163 & 165 ||
+||  205  || Multiple surgery reduction || Claim line reduced due to Multiple Surgeries- Medicare Guidelines ||
+||  206  || Invalid use of modifier || ||
+||  207  || Incidental charges reported, re-bill || Medicare no pay for incidental charges w/o complete hospital billing on UB04 ||
+||  208  || Provide pick up address and zip || Ambulance billing ||
+||  209  || Submit anesthesia code || ||
+||  210  || Units exceed medical necessity || 3M MUE Edit ||
+||  211  || Not eligible per CCHCS contract || ||
+||  212  || No RVP for this procedure || ||
+||  213  || Inappropriate use of modifier || ||
+||  214  || Covered inpatient service only || 3M OCE EDIT ||
+||  215  || CPT does not match description || ||
+||  218  || Invalid tax ID || ||
+||  219  || Inappropriate specification of || 3M OCE Edit/017 ||
+||  220  || Bilateral procedure OCE|| 219 & 220 used as one denial ||
+||  221  || Claim lacks required device code || ||
+||  222  || EDI-No tax ID submitted on claim || ||
+||  223  || Re-bill on HCFA 1500 claim form || ||
+||  224  || Service not billable to FI/MAC || Fiscan Intermediary / Medicare Administration ||
+||  225  || Provide service facility address || ||
+||  226  || Requires HCPCS on same line || 3M Edit 0048OCE 0048 ||
+||  227  || No payee data record || ||
+||  228  || Resubmit with height & weight || Dialysis claims only use # 228 & 229 together ||
+||  229  || of patient || ||
+||  230  || Dental service not covered || by CCIH ||
+||  231  || Covered w/ condition code only || UB charges ||
+||  232  || Non allowed service for OPPS || 3M Edit ||
+||  233  || Future service not payable || ||
+||  234  || Registry charge returned to CCHCS || ||
+||  235  || DME/Orthotics covered by CCHCS || ||
+||  236  || Surgeon cannot bill as assistant || Surgeon billing as the Assistant's charges ||
+||  237  || Condition code required on bill || 3M 00420CE ||
+||  238  || CCHCS refund received || ||
+||  239  || Resubmit with only one base rate || Ambulance billing ||
+||  240  || No charges were submitted || ||
+||  241  || Billable by hospital only || Contract based ||
+||  242  || EDI- No inmate Name submitted || ||  
+||  243  || EDI -No CDCR number submitted || ||
+||  244  || Claim lacks required device code || 3M edit 00710CE ||
+||  245  || Code not recognized by Medicare || Outpatient claims 3M edit 0028 ||
+||  246  || Code only billable to DMERC(RTP) || 3M edit 061 OCE ||
+||  247  || Verify Date of Service submitted || ||
+||  248  || Previously paid as assistant || 248 & 249 used together when assistant charge is billed by Surgeon ||
+||  249  || surgeon || ||
+||  250  || Units > 1 is inappropriate || 3M edit 0074 OCE ||
+||  251  || Invalid revenue code || ||
+||  253  || Incorrect billing of blood || ||
+||  254  || or blood products || 3M edit 0074 OCE ||
+||  255  || Trauma response w/ critical care || ||
+||  256  || Requires REV code with CPT code || 3M edit ||
+||  257  || Re-bill using procedure(s) code(s) || ||
+||  258  || as contracted || 257 & 258 used as one denial ||
+||  259  || Please submit Medicare fiscal || ||
+||  260  || intermediary letter || 259 & 260 used as one denial ||
+||  261  || Statutory exclusion list and not || ||
+||  262  || covered by Medicare outpatient || 3M edit ||
+||  263  || Co-surgeon not permitted || ||
+||  264  || ADJ-01 not completed/signed || ||
+||  265  || Incorrectly billed address || ||
+||  266  || in box 33, please resubmit  || 265 & 266 used as one denial ||
+||  267  || Admin Days denied by CCHCS || ||
+||  268  || Mutually exclusive to another || ||
+||  269  || CPT code billed || 268 & 269 used as one denial ||
+||  270  || Submit supporting documentation || ||
+||  271  || Per CCHCS UM inmate ineligible || ||
+||  272  || Per DH at CCHCS || ||
+||  273  || Additional paid to contracted || ||
+||  274  || rate || Use 273 & 274 as one denial ||
+||  275  || NDC code required for payment || ||
+||  276  || No inmate name submitted  || ||
+||  277  || Inmate not seen on || ||
+||  278  || Date of Service || Use 277 & 278 as one denial ||
+||  279  || DRG submitted does not match CMS || ||
+||  280  || group DRG code; submit || ||
+||  281  || corrected DRG code || Use 279, 280, & 281 as one denial ||
+||  282  || Claims with handwritten || ||
+||  283  || information are not accepted || Use 282 & 283 as one denial ||
+||  284  || Administrative fee included in || ||
+||  285  || reimbursement || Use 284 & 285 as one denial ||
+||  286  || Re-bill Health Net, date of || ||
+||  287  || service on new claim || Use 286 & 287 as one denial ||
+||  288  || Services packaged into PAC rate || ||
+||  289  || Medicare non-covered item / service || ||
+||  290  || Claim lacks required device code || ||
+||  291  || radio labeled product; resubmit || Use 290 & 291 as one denial ||
+||  292  || Clinical diagnostic lab services || ||
+||  293  || Claim service crosses contract with || ||
+||  294  || PPO, please split and re-bill || Use 292 & 293 as one denial ||
+||  295  || Incidental services packaged || ||
+||  296  || into APC rate || Use 295 & 296 as one denial ||
+||  297  || Adjustment / refund error || ||
+||  298  || NDC submitted is invalid || ||
+||  299  || Not approved per ADJ-01 form || ||
+||  300  || Add on code not reimbursable || ||
+||  301  || because valid primary CPT absent || Use 300 & 301 as one denial ||
+||  302  || Invalid age/gender for CPT code || ||
+|| '''303''' || '''Invalid age/gender for HCPCS''' || ||
+||  304  || E&M service previously paid for || ||
+||  305  || DOS, only one allowed per day || Use 304 & 305 as one denial ||
+||  306  || Patient seen within last 3 yrs || ||
+||  307  || by physician, submit established || ||
+||  308  || CPT code || Use 306, 307, & 308 as one denial ||
+||  309  || Patient seen within last 3 yrs || ||
+||  310  || by physician, an established || ||
+||  311  || code was reimbursed || Use 309, 310, & 311 as one denial ||
+||  312  || Included in global surgical || ||
+||  313  || package for major surgery and is || ||
+||  314  || not separately reimbursable || Use 312, 313, & 314 as one denial ||
+||  315  || Included in global surgical || ||
+||  316  || package for minor surgery and is || ||
+||  317  || not separately reimbursable || Use 315, 316, & 317 as one denial ||
+||  318  || This procedure is incidental to || ||
+||  319  || another service on this Date of || ||
+||  320  || Service and is not reimbursable || Use 318, 319, & 320 as one denial ||
+||  321  || This service is not reimbursable || ||
+||  322  || based on the place of service || Use 321 & 322 as one denial ||
+||  323  || This service is not covered || ||
+||  324  || An Assistant Surgeon, Co-Surgeon || ||
+||  325  || or Team Surgeon for this CPT is || ||
+||  326  || unnecessary and not reimbursed || Use 324, 325, & 326 as one denial ||
+||  327  || An Assistant Surgeon, Co-Surgeon || ||
+||  328  || or Team Surgeon for this CPT || ||
+||  329  || requires additional documentation || Use 327, 328, & 329 as one denial ||
+||  330  || Procedure submitted with more || ||
+||  331  || than one multiple surgeon || ||
+||  332  || modifier || Use 330, 331, & 332 as one denial ||
+||  333  || Invalid modifier for procedure || ||
+||  334  || Duplicate charge || ||
+||  335  || Exceeds the appropriate || ||
+||  336  || number of units per day || Use 335 & 336 as one denial ||
+||  337  || Exceeds the appropriate || ||
+||  338  || units for defined time frame || Use 337 & 338 as one denial ||
+||  339  || Component included with other || ||
+||  340  || CPT billed for Date of Service || Use 339 & 340 as one denial ||
+||  341  || Mutually exclusive to another || ||
+||  342  || procedure billed || Use 341 & 342 as one denial ||
+||  343  || Unlisted procedure requires || ||
+||  344  || additional documentation || Use 343 & 344 as one denial ||
+||  345  || Not medically necessary based on || ||
+||  346  || National Coverage Determination || Use 345 & 346 as one denial ||
+||  347  || Included in global || ||
+||  348  || obstetric package || Use 347 & 348 as one denial ||
+||  349  || Procedure is part of a lab panel || ||
+||  350  || and is not reimbursable || Use 349 & 350 as one denial ||
+||  351  || CPT is add on code and cannot be || ||
+||  352  || billed as a standalone code || Use 351 & 352 as one denial ||
+||  353  || Included in global surgical || ||
+||  354  || package for another CPT billed || Use 353 & 354 as one denial ||
+||  355  || Status B code payment included || ||
+||  356  || in payment for other services on || ||
+||  357  || same Date of Service || Use 355, 356, & 357 as one denial ||
+||  358  || Invalid diagnosis code || ||
+||  359  || Status T code included in other || ||
+||  360  || CPT payment for same DOS || Use 359 & 360 as one denial ||
+||  361  || Another E&M service billed for || ||
+||  362  || same provider and same DOS ||  ||
+||  363  || this CPT will not be reimbursed || Use 361, 362, & 363 as one denial ||
+||  364  || Global period applies, same || ||
+||  365  || CPT billed with previous DOS || Use 364 & 365 as one denial ||
+||  366  || Refund received and applied || ||
+||  367  || CPT code not valid for date of || ||
+||  368  || service billed || Use 367 & 368 as one denial ||
+||  369  || Unlisted procedure or service || ||
+||  370  || is not reimbursable || Use 369 & 370 as one denial ||
+||  371  || CPT submitted with multiple || ||
+||  372  || units exceeding the CMS ||  ||
+||  373  || Medically Unlikely Edit || Use 371, 372, & 373 as one denial ||
+||  374  || CPT/HCPCS is not valid for Date || ||
+||  375  || of Service submitted on claim || Use 374 & 375 as one denial ||
+||  376  || Invalid diagnosis code submitted || ||
+||  377  || Submit supporting medical || ||
+||  378  || documentation || Use 377 & 378 as one denial ||
+||  379  || Invalid principle DX code || Health Net denial ||
+||  380  || Service not separately payable || Health Net denial ||
+||  381  || Code2 of a Code1/Code2 || ||
+||  382  || paid; needs modifier || Health Net denial; use 381 & 382 as one denial  ||
+||  383  || Service units out of range || Health Net denial ||
+||  384  || Invalid HCPCS code || Health Net denial ||
+||  385  || Modifier required for payment || Health Net denial ||
+||  386  || Diagnosis code requires ALS || ||
+||  387  || HCPCS code. || use 386 & 387 as one denial ||
+||  388  || Not payable due to invalid base ||  ||
+||  389  || rate HCPCS code || use 388 & 389 as one denial ||
+||  391  || Revenue code requires HCPCS code || Health Net denial ||
+||  392  || Packaged / Incidental services || Health Net denial ||
+||  393  || Invalid bill type || Health Net denial ||
+||  394  || Invalid Place of Service || Health Net denial ||
+||  395  || Excluded from negotiated rate || Health Net denial ||
+||  396  || Provider compensation for this || ||
+||  397  || service is zero per Coventry || ||
+||  398  || Provider agreement || Health Net denial; use 396, 397, & 398 as one denial ||
+||  399  || Multiple medical visits, same || ||
+||  400  || revenue code, same date without || ||
+||  401  || condition code G0 || Health Net denial; use 399, 400, & 401 as one denial ||
+||  402  || No additional payment due, ||  ||
+||  403  || included with additional pricing || Health Net denial; use 402 & 403 as one denial ||
+||  404  || Claim lacks required device code || ||
+||  405  || Claim lacks required || ||
+||  406  || radiolabeled product || Health Net denial; use 405 & 406 as one denial ||
+||  407  || Invalid revenue code || Health Net denial ||
+||  408  || Invalid principle procedure || Health Net denial ||
+||  409  || Procedure/Sex conflict || ||
+||  410  || Procedure may only be performed || ||
+||  411  || in an inpatient setting || Health Net denial; use 410 & 411 as one denial ||
+||  412  || Place of Service not valid || ||
+||  413  || for precedure billed || Use 412 & 413 as one denial ||
+||  414  || Invalid procedure to modifier || ||
+||  415  || Lab test is component of a lab || ||
+||  416  || panel and require being || ||
+||  417  || billed using the panel code || Use 415, 416, & 417 as one denial ||
+||  418  || HSS ASC invalid Bill Type or || ||
+||  419  || Place of Service || Use 418 & 419 as one denial ||
+||  420  || Provider is not contracted for || ||
+||  421  || services submitted with this || ||
+||  422  || Bill Type/POS || Health Net denial; use 420, 421, & 422 as one denial ||
+||  423  || Medical visit with procedure || ||
+||  424  || without "25" || Health Net denial; use 423 & 424 as one denial ||
+||  426  || CMS rates not available || Health Net denial ||
+||  427  || Original bill required to price || ||
+||  428  || late charges || Health Net denial; use 427 & 428 as one denial ||
+||  429  || Inpatient service not paid || ||
+||  430  || under OPS || Health Net denial; use 429 & 430 as one denial ||
+||  431  || Packaged service/item; no || ||
+||  432  || separate payment || Health Net denial; use 431 & 432 as one denial ||
+||  433  || Service not covered by Medicare || ||
+||  434  || for free standing ASC || Health Net denial; use 433 & 434 as one denial ||
+||  435  || Component of comprehensive || ||
+||  436  || procedure not allowed || Health Net denial; use 435 & 436 as one denial ||
+||  437  || Service not billable to the || ||
+||  438  || fiscal intermediary || Health Net denial; use 437 & 438 as one denial ||
+||  442  || Invalid ICD procedure codes used || ||
+||  443  || Additional charges added || ||
+||  444  || Charges billed as non-covered || ||
+||  447  || No allowance for Asst. Surgeon || ||
+||  448  || NPI number does not match || ||
+||  449  || Physician in box 31 || ||
+||  450  || Therapy service requires modifier || Health Net denial ||
+||  451  || Invalid principle diagnosis || Health Net denial ||
+||  452  || Present on Admission || ||
+||  453  || POA codes are missing || Health Net denial; use 452 & 453 as one denial ||
+||  454  || Not medically necessary based on || ||
+||  455  || local coverage determination || Bloodhound denial; use 454 & 455 as one denial ||
+||  456  || NDC# submitted has been || ||
+||  457  || deactivated for this DOS || Use 456 & 457 as one denial ||
+||  458  || Status N code is non-covered || Bloodhound denial ||
+||  463  || Remit address does not match || ||
+||  464  || BIS account information on file || Use 463 & 464 as one denial ||
+||  466  || Zip code point of pick up || ||
+||  467  || is outside of supplier's contract || Health Net denial; use 466 & 467 as one denial ||
+||  468  || Invalid ADA code; resubmit || ||
+||  469  || Please verify charges submitted || ||
+||  470  || Incidental procedure not || ||
+||  471  || separately reimbursed || OCE Edit 047-Use 470 & 471 as one denial ||
+||  472  || Resubmit claim with correct || ||
+||  473  || NPI number || Use 472 & 473 as one denial ||
+||  475  || Discharge status is invalid || Use with code 197 ||
+||  481  || Invalid or missing CMG code || Health Net denial ||
+||  484  || G0379 only allowed with G0378 || OCE Edit 0058 ||
+||  487  || Service provided same day as || ||
+||  488  || an inpatient procedure || OCE Edit 049-Use 487 & 488 as one denial ||
+||  493  || Vendor should re-bill through || ||
+||  494  || the hospital/surgery ctr/phy || Use 493 & 494 as one denial ||
+||  500  || Packaged surgical procedures || ||
+||  501  || include operation and || ||
+||  502  || uncomplicated post-op care || Use 500, 501, & 502 as one denial ||
+||  503  || Non-covered - inmate is a donor || ||
+||  506  || RUG values missing || ||
+|| '''507''' || '''CCHCS UM Audit required''' || ||
+||  511  || Invalid DRG code || ||
+||  513  || Line 1 does not match the || ||
+||  514  || date of service billed in the || ||
+||  515  || statement period submitted || Use 513, 514, & 515 as one denial ||
+||  516  || Line service date is invalid || ||
+||  517  || in box 32 for Place of Service || Use 516 & 517 as one denial ||
+||  518  || Incorrect Bill Type || ||
+||  519  || Admission Source Code, box 15 || ||
+||  520  || missing or invalid || Use 518, 519, & 520 as one denial ||
+
+codes in '''bold''' are considered most relevant for DPS&C