As part of the implementation of the Medicare Administrative Contractor or MAC, the Centers for Medicare and Medicaid (CMS) requires one set of consistent reason codes. Highmark Medicare Services has compared the current Pennsylvania, District of Columbia Metropolitan Area and Maryland reason codes for consistency. Based on this comparison, the following reason codes will be changed as of August 1, 2008. Please refer to page 8 of the J12 SIPP II Newsletter dated July 15, 2008 for additional information for the consolidation of reason codes. The following abbreviations were used to represent the current and new actions that will be taken on the reason codes:
S = Suspend
T = Return to Provider
R = Reject
D = Deny
Reason Code |
Description |
PA |
MD |
New |
128A3 |
The Guarantee of Payment code 20 must be equal to or greater than the admission date. Please correct and resubmit. |
T
|
S |
T |
128C5 |
When the Guarantee of Payment (occurrence code 20) code is used and the admission date and the from date are not the same, the number of days between the admit and the day before the from date must be subtracted from the number of days that can be guaranteed. When the billing dates cover the period 12/24 thru 1/2 the maximum guarantee is 13 days less the number of days in this calculation. If the billing dates do not cover this period, the maximum guarantee is 12 days less the number of days in this calculation. The result must be equal to less than the days claimed under the Guarantee of payment. Please recalculate, correct and resubmit.
|
S
|
T |
T |
30919 |
Duplicate Claim |
S |
T |
T |
30928 |
An adjustment cannot be preformed against a claim in a post payment location. |
S |
T |
S |
31157 |
Cardioverter defibrillator pulse generator processing with occurrence code 32 |
D |
R |
R |
31158 |
Cardioverter defibrillator pulse generator processing with condition code 78 |
D |
R |
R |
31160 |
Cardioverter defibrillator pulse generator processing , no QR modifier present |
D |
R |
R |
32019 |
Provider termination date versus through date of claim |
S |
T |
T |
32206 |
Revenue code invalid for TOB |
R |
S |
S |
32438 |
PET scan processing |
S |
T |
T |
34026 |
Medicare Secondary Payer (MSP) – Our records indicate the beneficiary has coverage through a Public Health Service or other Federal Agency that is primary to Medicare. Please submit the claim to the primary insurer. |
S |
R |
R |
37540 |
The incoming adjustment claim from a PPS hospital versus patient status on original claim |
S |
T |
T |