PA/MD vs NJ Reason Code Compare (8/20/2008)

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, Maryland and New Jersey reason codes for consistency. Based on this compare, the following reason code statuses will be changed as of September 1, 2008. The follow abbreviations were used to document status:

S = suspend, T = Return to Provider, R = Reject, D = Deny, P = Pay

Reason Code	Description	Current Status	New Status
32919	Occurrence code 70 without qualifying stay dates on an initial SNF bill	T	R
32920	The 3-day qualifying stay requirement not met	S	R
33553	'0001' Revenue Code Line is equal to zero	S	T
33885	Invalid number of lines	S	T
34915	Revenue code invalid for TOB 12X or 22X, GA modifier present	D	T
36224	ESRD claim for a beneficiary who has not selected method two (remark code 039)	S	R
36328	Number of home dialysis visits exceed routine limit and justification not provided	S	R
36329	Maximum allowance for erythropoietin (EPO) has been reached	T	R
36330	Maximum allowance for this ESRD service has been reached	S	R
36342	A HCPC on this ESRD claim did not have the requested justification	S	R
36353	Units of EPO or revenue lines of Aranesp have exceeded the monthly limit	S	R
36357	Dialysis services exceeded the routine limit and justification not provided	S	R
36362	Units of EPO or revenue lines of Aranesp exceeded the monthly limits and justification not provided	S	R
36375	The dialysis services have exceeded the limit routinely allowed for date of service. Justification needed	S	R
37207	Claim finalized – Page 10 of claim contains a zero amount in the “PROV REIM RATE” field and also contains a “yes” in the “PROV REIM RATE = 0” field	P	S
37210	Claim has been approved for IME payment	S	P
37507	Inpatient Home Health percent or per diem or PIP reimbursement rates are equal to zeros. Contact the Provider Reimbursement department.	S	T
38001	Inpatient claim contains service dates that equal or overlap an inpatient claim which previously denied. An adjustment must be submitted.	S	R
38009	Inpatient claim contains a service date that equals a previously submitted inpatient claim and the Medicare providers are not equal.	S	R
38010	Inpatient claim contains dates which equal a previously submitted SNF claim. Patient status 07 not on either claim.	S	R
38011	Inpatient claim contains dates which equal a previously submitted SNF claim. Patient status 07 not on either claim.	S	R
38013	Inpatient claim overlaps with a previously processed inpatient bill that has the same admission date.	S	R
38014	Inpatient claim contains statement from or statement through date which equals a previously submitted SNF claim and the admission is equal on both claims.	S	R
38015	Inpatient claim contains statement from or statement through date which equals a previously submitted SNF claim and the admission is equal on both claims. Patient status 07 not on either claim	S	R
38016	Inpatient claim contains statement from or statement through date which equals a previously submitted SNF claim and the admission is equal on both claims. Patient status 07 not on either claim	S	R
38017	Inpatient claim with TOB 11X, 18X, or 41X contains service dates that overlap a previous claim with TOB 11X, 18X, or 41X	S	R
38018	Inpatient claim with TOB 11X, 18X, or 41X contains service dates that overlaps a previous SNF claim with TOB 21X, 28X, or 51X	S	R
38019	SNF claim with TOB 21X, 18X, or 51X contains service dates that overlaps a previous inpatient SNF claim TOB 21X, 18X, or 51X	S	R
38020	SNF claim with TOB 21X, 18X, or 51X contains service dates that overlaps a previous inpatient claim TOB 11X, 18X, or 41X	S	R
38021	Incoming or prior claim for one-day stay versus patient status. Provider numbers are not equal.	S	R
38022	TOB 12X or 22X overlaps with DOS of previously processed inpatient claim	S	R
38023	Outpatient SNF claim overlaps a previously processed inpatient SNF claim	S	R
38024	ESRD claim overlaps previously a previously processed inpatient ancillary claim	S	R
38038	Duplicate outpatient claim	S	R
38040	HCPCS G0369 & G0370 on two separate claim and diagnosis requirements.	S	R
38041	Outpatient claim overlaps with previously processed inpatient claim	S	R
38046	Duplicate charges	S	R
38047	Duplicate charges.	S	R
38061	ESRD duplicate	S	R
38064	ESRD duplicate claims	S	R
38068	Inpatient claim overlaps with previously processed inpatient claim	S	R
38069	Inpatient claim – verify date of service	S	R
38076	Inpatient ancillary claim overlaps previously processed claim – verify information.	S	R
38077	Outpatient claim duplicate to medically necessary denied claim	S	R
38082	Adjustment duplicate	T	R
38085	Adjustment duplicate	S	R
38089	Late charge bills	T	R
38092	Outpatient duplicate with multi-channel lab HCPCS	S	R
38097	TOB equals 13X or 14X but overlaps with a 72X bill	T	S
38099	Duplicate revenue codes.	S	R
38106	.PPS inpatient claim provider number	S	R
38109	Inpatient versus outpatient duplicate	S	R
38111	Duplicate influenza or pneumococcal vaccine	S	R
38112	Overlapping claims – multiple conditions	S	R
38114	PPS inpatient claims – different provider numbers	S	R
38135 – 38139	Outpatient duplicate – lab charges	S	R
38142	Late charge bills for anesthesia, pharmacy or supplies with other diagnostic procedures	S	R
38143	Late charge bills for specific revenue codes and radiology charges	S	R
38149	Duplicate outpatient lab charges.	S	R
38151	Overlapping lab charges	S	R
38153	Duplicate statement from and through dates	S	R
38154	Lab test versus panel code	S	R
38155	Duplicate – lab codes	S	R
38305	TOB with same admission date	S	R
38306	Duplicate	S	R
39721	Requested information not received timely	T	R
39722	Requested information not received timely.	T	R

J12 MAC Transition(* = off-site link)

J12 MAC Transition
(* = off-site link)