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