PA/MD vs NJ Reason Code Compare (8/29/2008 Final)

As part of the Reason Code Consolidation for J12 MAC, we have identified additional reason codes where our disposition of the code varies from the current method utilized by Riverbend. In some situations, the claim may still have been handled in the same manner, but would have suspended prior to being returned to you for correction. Those variations have also been included in this listing.

The following abbreviations were used to document status:

S= Suspend, T= Return to Provider, R= Reject, D= Deny, P= Pay, A= Accept

Reason Code	Description	Current Status	New Status
09904	More than 450 lines	T	S
10406	Type of bill (TOB) error	S	T
10410	Revenue codes 631 – 633, must show national drug code for each revenue code	S	T
10413	TOB 85X, DOS error	T	S
12303	Number of units exceeds number of days	S	T
12814	Guarantee of payment code 20, admission date, and from date are the same	S	T
12815	Guarantee of payment code 20, admission date, and from date are not the same	S	T
12816	Date of guarantee of payment code 20 must be ≥ date for benefits exhausted under occurrence code 23	S	T
12817	Date of payment guarantee under payment code 20 plus utilization must not exceed through date	S	T
13501	Condition code 60, 61, and 65 may not be on the same bill	S	T
13511	Condition code 60, 61, and 65 may not be on the same bill	S	T
13531	Condition code 60, 61, and 65 may not be on the same bill	S	T
14402	Respite hours must not be < 3 or > 80 hours for bill type 34X	S	T
15421	Noncovered revenue charges for revenue code 0001	S	T
19947	Inpatient claims with RUG provider	S	T
30714	Roster TOBs (12X, 22X) with condition code 21 require discharge date	S	T
30800	Full denial determination made by PRO	S	R
30821	PRO denial for records	S	R
30902	No record of claim submitted for adjustment	S	T
30919	Duplicate claim	S	T
30929	Cancel for post payment location	S	T
30943-30945	UB92 adjustment frequency errors	T	S
30957	Type of frequency is invalid	S	T
30961	PIP versus non PIP	S	T
30962	Condition code 64 on original claim	S	T
30963	Cross reference DCN invalid	S	T
30990	Invalid HIC	S	T
31004	Adjustment/Cancel return	S	T
31015	TOB frequency error	S	T
31031	PRO date invalid	S	T
31082	Claims receipt date error	S	T
31086	Pre-entitlement psychiatric day count error	S	T
31092	Adjustment bill, TOB frequency error	S	T
31094	Total covered charge cannot be > zero	S	T
31112-31113	UB92 frequency errors	S	T
31142	Patient paid amount > zero	S	A
31146	Condition Code EY	S	T
31148	Religious Non Medical Healthcare Institution	T	T
31149	Railroad Retirement Beneficiary	S	R
31150	Railroad Retirement Beneficiary	S	R
31151-31152	Demo Indicator error	S	R
31201-31230	Occurrence code – date exceeds through date	S	T
31231	Condition code B0, primary payer not equal Z	S	T
31232	NOA and demonstration code 07 or 08 versus bill type	S	T
31240	Occurrence code 32 error	T	R
31254	Date error	S	T
31305	Non covered charge error	S	R
31322	Condition code 21	S	T
31359	Value Code 05	S	T
31396-31397	Multiple occurrence or occurrence spans	S	T
31400	Occurrence code 22	T	S
31402	Occurrence code 22	T	S
31415	Claim submission error	A	T
31505	SNF transfer code > spaces	S	T
31525-31526	TOB 18X, 21X, or 51X, SNF transfer code errors	T	S
31545	Condition code 20 but no occurrence code 21 or 22 present	T	S
31573	Statement from and through date must equal	S	T
31639	Covered and non-covered charges on same line	T	S
31640	TOB not valid for provider	T	S
31761	HCPCS codes G0245 – G0247 revenue code error	S	T
31762	G0247 without G0245 or G0246	T	S
31765	Billing error on bill types and revenue codes for G0281 and G0282	R	T
31772	ESRD diagnosis code was not reported	T	R
31804	The number of units for revenue code 0901 must be ≥ the number of covered days	R	S
32003	Admit date is after the provider’s termination date	S	T
32005	Dates of service are prior to your effective date for a participating provider	T	R
32013	Provider’s termination date is invalid	T	S
32020	Provider not eligible to bill State revenue code 0091	S	T
32024	Admit date is greater than the provider’s termination date	S	T
32026-32028	Medical Assistance Facility demo errors	S	T
32048-32049	Admit date conflict with provider’s effective and termination dates	S	T
32056	Covered and non-covered days < than 60	T	S
32059	Claim billing error	S	T
32081	IRF PPS claim error	R	S
32084	Total charges on this line must be blank or zero	S	T
32098	Paper claim conflicting receipt dates with paper approval date	S	R
32101	Demo indicator not equal to P and VA/demo plan equal to P	S	R
32106	Fed. Tax number not on claim	S	T
32114	Zip code of 5 or 9 numeric digits is required	S	T
32151	Operating Physician UPIN	S	T
32153	Operating Physician Sanctioned	D	S
32209	Outpatient claim error	S	T
32211	Number of blood units not equal to the number of blood units not replaced	S	T
32225	J8530, J8560, J8600, or J8610 covered charges > 0.00 but covered units = 0	T	S
32232	Revenue code error	T	S
32233	Non-covered charge amount either not numeric or is greater than the total charge for the line item	S	T
32242	Revenue code is non-billable for this type of bill and covered charges are > than 0	T	S
32249	Revenue code 603 can appear only once	S	T
32257	Invalid revenue code	S	T
32258	Revenue code 0403 must be reported with HCPC G0202, G0203, 77052 or 77057	R	T
32276	Revenue code versus covered days	T	S
32278	Outpatient claim with lab servicess	T	S
32289	HCPC and sex do not agree	S	T
32290	G0129, G0172. or Q0082 reported the covered unit must be = to 1	S	T
32302	Approval period for the investigational device in the FDA clinical trial has not begun	S	T
32303	Approval period for the investigational device in the FDA clinical trial has expired	R	T
32373	G0375 and G0376 may only be billed for TOB 2X, 13X, 14X, 22X, 23X, 34X, 71X, 73X, 74X, 75X, 83X, and 85X.	T	R
32378	Method I CAH that chooses to give up the CRNA pass through exemption cannot submit Rev. Code 0964 on TOB 85X or 11X	T	S
32388	AR modifier cannot be billed by Method II CAH on or after 7/1/08	T	S
32397	Method II CAH that chooses to give up the CRNA pass through exemption must submit QZ	S	T
32401-32404	Invalid HCPCS code errors	S	T
32407	Osteoporosis injection allowed one time	S	T
32426	Invalid HCPCS code	R	T
32447	Non-winner laboratory for demo-covered services provided to a beneficiary residing in the competitive bidding area	S	R
32809	Medicare only pays for abortion services resulting from rape, incest, or if the life of the mother is endangered	S	R
32901	Type of bill frequency code is equal to 7, but the adjustment reason code is missing or invalid	T	S
32917	Your facility is not approved to bill heart transplants	T	R
32922	SNF demand bill but the span code 70 associated dates are beyond the statement from date	S	T
32948	S & I code of 93556 reported on more than one revenue code line or the unit is greater than 1	S	T
32950	TOB 73X and facility code is not a single facility or independent FQHC or a multi-facility or provider based	S	T
32954	SNF RUG phase 4 claim, then 2 or more revenue codes 42X, 43X, or 44X must be present	S	T
32960	TOB = 85X and provider payment method is all-inclusive and the date of service is < than 7/1/01 then the revenue code must be 510	S	T
32961	Rural primary care hospital bills TOB 14X, only acceptable revenue codes are 300 – 319	S	T
32967	Condition code 69 is present and TOB is not equal to 11X	T	R
32973	Please verify statement of intent is on file	S	T
32975	Non-covered charges are not allowed for revenue code 0023	S	T
32990	L8110 or L8120 is reported and AW modifier not present	T	R
34911	Cryosurgery outpatient requires TOB 13X. 83X, or 85X; from date on or after 1/1/01; revenue code = 0361, HCPC = 55873; and diagnosis code = 185	S	T
34912	Cryosurgery inpatient requires TOB 11X.; claim discharge date on or after 7/1/99; procedure code = 60.62; and diagnosis code = 185	R	T
34918	TOB on HCPCS G0377	A	T
34922	SNF demand bill but the span code 70 associated dates are beyond the statement from date	R	T
36103	ESRD claim with condition code 76 and no method selection on file	S	T
36105	ESRD claims are not allowed to span beyond a single month	A	T
36106	Condition code 70 to 76 is required	S	T
36125	ESRD claim error	S	T
36127	Revenue code 83X is present on an ESRD claims which also contains revenue code 88X	S	T
36133	Revenue code 88X is present on an ESRD claims which also contains revenue code 82X, 83X, 84X, or 85X	S	T
36151	72X TOB submitted with Trial 49 in the treatment authorization field and the revenue code is not equal to 082X	S	T
36152	72X TOB submitted with Trial 49 in the treatment authorization field	S	T
36173	Ultrasonic osteogenic stimulator error	R	T
36174	Ultrasonic osteogenic stimulator error	S	T
36186	ESRD claim with revenue code 831 without necessary ESRD hours present	S	T
36187	Value code amounts must be > than 1 and < than 100 #67 IPD hours	S	T
36200	During HCPC pricing, charges were cut to 0	S	T
36201	Lab - quantity more than one	S	T
36222-36223	ESRD claim errors	S	T
36232	ESRD claim error	S	T
36339	ESRD dialysis home support	S	T
36340-36341	ESRD	S	T
36358	Dialysis services	S	T
36372	Dialysis services	S	T
36376	Dialysis services	S	T
36377	Hepatitis B vaccine units	S	T
36384	HCPCS error	R	S
36385-36387	HCPCS billing errors	S	T
36436	ASC multiple cataract codes reported	T	S
36607	ESRD billing error	S	T
36611-36615	ESRD pricer errors	S	T
36618-36619	ESRD pricer errors	T	S
37021	Transfer error	S	T
37036	PPS return code 67	S	T
37037	Verify non-covered days and dates	S	T
37045	Lifetime reserve day error	S	T
37048	Occurrence code 47 date error	S	T
37054-37056	IRF pricer errors	S	T
37058	IRF pricer error	S	T
37061-37062	IRF pricer error	S	T
37063-37064	Demonstration code errors	S	T
37067	IRF pricer error	S	T
37074	IRF pricer error	S	T
37079	LTCH pricer error	S	T
37083	LTCH pricer error	S	T
37092	LTCH pricer error	S	T
37211	Encounter data claim approved for payment	S	P
37227-37229	Bill type 89a, 89B, or 89D has finalized	S	P
37303	IRF pricer error	S	A
37304	IRF pricer error	T	S
37305	IRF pricer error	T	S
37507	IRF pricer error	S	T
37535	Provider submitted adjustment	S	T
37540	Incoming adjustment error	S	T
37543-37545	Condition code errors	S	T
37549	Adjustment error	S	T
37554	Inpatient claim with condition code 69	T	S
37574	No-pay code equal to 'N' must be present	R	T
37590	MA-ID returned by CWF on trailer 05 does not match the provider supplemental payment rates record	T	S
37591	Provider effective and term dates conflict with CWF records	T	S
38001	Claim contains service dates that equal or overlap a previous inpatient claim which was denied	S	R
38065	Multiple claims submitted with AAMC HCPCs codes	S	T
38093	Duplicate claim	S	T
38098	Duplicate claim	S	T
38101- 38103	Duplicate claim	S	T
38107	Incoming NOE has same admit date and same provider as an existing NOE	S	T
38115	Service dates on ESRD claim overlap an inpatient hospital claim	S	T
38140-38141	SNF claim is within the same benefit period as a previously submitted SNF claim	S	T
38156	Valid NOE is not on file for claim date	S	T
39050-39052	Payment not eligible for HMO unless emergency services were rendered.	R	S
39504-39506	Medicare is unable to determine which date(s) to utilize in the calculation of noncovered days	S	T
39519	Provider number on the original bill is different from the adjustment	S	T
39611	Non-covered days, without an occurrence span code indicating non-coverage.	T	S
39928	Claim Level Reason Code all Lines Denied	R	D
151E6	Total charges must be greater than zero for each detail revenue code	T	S
1280J	Occurrence code 17 must have a date that is prior to or equal to the statement covers from date on the claim.	S	T
1280L	Occurrence code 39 may not have value code 73 present	S	T
128AA	Covered days exceed the number of calendar days between the statement from date and the date on which benefits were exhausted	T	S
128AD	Occurrence is only valid for SNF inpatient bill types	T	S
128CM	The occurrence code '42' date does not equal the service thru date on the claim.	T	S
1460B	Value code conflicts with bill type	S	T
1461B-1467B	Value code conflicts with bill type	S	T
151I7	Claim is noncovered and there are blood pints shown in the deductible field and value code 06 with money amount is present.	S	T
151O7	Total deductions and total charges conflict	T	S
151P7	Claim is noncovered and there are blood pints shown in the deductible field and value code 06 with money amount is present.	S	T
194G2	Total charges incomplete, invalid, or missing.	S	T
3719C	Beneficiary is enrolled in the Medicare choices demonstration.	S	T
3719E	Claim is in Medicare demonstration.	S	T
3719V	Claim is Veterans Administration (VA) demonstration.	S	T
4S413-4S417	The remark from date or CMS 832 effective date is not entered.	S	T
C7020	Service dates on the ancillary claim are duplicate to another facility	S	R
C7050	An outpatient bill type overlapping an inpatient bill type.	S	R
C7055	Dates of service overlap or duplicate a previously processed outpatient claim.	R	T
C7109	Diagnostic services included in the payment for the inpatient claim.	S	R
C7111-C7114	Dates overlap another claim	S	R
C7119-C7122	Dates overlap another claim	S	R
C7240-C7241	Duplicate to another claim	S	R
C7247	Duplicate to another claim	S	R
C7248	Duplicate to another claim	S	T
C7249	Duplicate to another claim	S	R
C7251	Duplicate to another claim	S	R
C7253-C7255	Duplicate to another claim	S	R
C7257	Duplicate to another claim	S	R
C7266	HCPC code 11055-11057, or 11719-11721 has been paid within 6 months of G0245-G0247	S	R
C7267	The interrupted stay is greater than the specified number of days allowed on an LTCH PPS provider	S	T
C7268	LTCH PPS provider's admit date is less than the specified number of days allowed	S	R
C7270-C7273	Duplicate to another claim	S	T
C7275-C7276	Duplicate to another claim	S	R
C7280	Inpatient claim with incorrect patient status due to transfer to another facility.	S	R
C7281	The detail line item date of service is within or equals a RNHCI claim	S	T
C7283	Duplicate to another claim	S	T
C7296	HCPCS 'G0332' only allowed once per day.	R	D
C729H	IRF PPS claim improperly coded as discharge	T	R
C7530	Less than 30 day lapse between one bill thru date and the next bill from date.	S	R
C7531	Discharge date of one PPS inpatient claim is equal to the admission date of another PPS inpatient claim	A	S
C7532	Outpatient claim with same provider and services and dates span a consecutive period of six months or more.	A	T
C7535	Outpatient claim with dates of service equal to or overlapping a denied Part B bill.	A	R
C7545	From & thru dates equal or overlap a previously processed outpatient claim.	A	R
CT020	Trailer 20 is being received on a disposition code CR.	A	S
D7171	From/thru dates of service or if present occurrence span code 72 dates equal or overlap Part B date of servi	A	R
D7531	Discharge date of equal to the admission date of another PPS inpatient claim	A	R
D7532	Outpatient claim with same provider and same services and dates span a consecutive period of six months or more.	A	S
D7545	Inpatient claim overlapping a previously processed outpatient claim	A	S
D7549	CWF IUR code returned with informational unsolicited response, this is informational only.	S	R
D7550	CWF IUR code returned with informational unsolicited response, this is informational only.	A	R
D7551	CWF IUR code returned with informational unsolicited response, this is informational only.	S	R
D7611	Duplicate to another claim	R	T
D7612	Duplicate to another claim	R	T
D7614	Duplicate to another claim	S	T
D7615-D7616	Duplicate to another claim	S	T
D7621-D7624	Duplicate services from different providers	R	T
D7631	Duplicate services from different providers	R	T
D7636	Duplicate services from different providers	R	T
D7641-D7644	Duplicate services	R	T
D7651-D7654	Duplicate services	R	T
D7661-D7664	Duplicate services	R	T
E0014	Invalid demonstration number	R	S
E0401	TOB is invalid, inconsistent with the provider number, or not allowed	S	T
E0406	Invalid HCPC code for date reported	T	R
E1503	The date of admission is more than 30 days after the through date of the qualifying stay.	S	R
E2305	Utilization and/or non-utilization days can not be present on a hospital inpatient or SNF inpatient late-charge claim.	S	R
E2307	Verification of the patient status code required	S	T
E2501	Coinsurance days incomplete or inconsistent with TOB	T	S
E2503	Inpatient benefits have been incorrectly applied	T	S
E28#0	Occurrence code 42 date is invalid or missing.	S	T
E281A	The non-covered days do not equal the time to when the benefits exhaust date was set.	R	T
E281E	More than one benefits exhausted date occurrence is present on the claim.	S	T
E2829	Hospial/SNF: utilization days exceed the number of days from the from date through the date active care ended,	T	S
E282A	The non-covered days do not equal the time to when the benefits exhaust date was set.	R	T
E282E	More than one benefits exhausted date is present on the claim.	S	T
E2831	The date associated with the indicated occurrence code is impossible, incomplete or missing	S	T
E2839	Utilization days exceed the number of days from the from date through the date active care ended	T	S
E33#6	Screening services billed multiple times on the same claim	R	S
E3312-E3313	Qualifying hospital stay of 3 days not met	S	R
E35#1	Condition code error	R	T
E461L	Value code error	R	T
E462B	More than one coinsurance value code	S	T
E462C	Hospital in-patient late charge contains deductible	S	T
E463C-E467C	Hospital inpatient late charge claim errors	S	R
E46TO	Blood deductible pints present, must have value code 06	R	T
E51#3	Revenue code unit missing or invalid	R	T
E61#P	HCPCS modifier error	R	T
E61#R	Invalid TOB or revenue code error	R	T
E61#S	G0247 cannot be paid when G0245 or G0246 are not payable	R	T
E61#T	G0245/G0246 billing error	S	T
E61#U	Yearly limits exceeded for non blood services	R	T
E61#V	G9041 – G9044 must have line item date of service	R	T
E6101-E6102	Total charge for revenue code 001 errors	S	T
E6105	Multiple revenue code 0001 lines present	S	T
E8301	PAP smear submission error	R	T
E8303	Prostrate screen sex code error	S	T
E9101	Invalid IDE number	S	R
E9300	Operating physician identification number missing	S	T
E9407	Invalid principal diagnosis	S	T
E9409	DRG calculation error	S	T
E9901	Revenue code 001 error	S	T
E9902	Inpatient claims with no accommodation charge	S	T
E9933	Mammography billing error	S	T
E9946	Colorectal cancer screening TOB error	R	T
EA002-EA003	Invalid HIC errors	S	T
EA031	GHO encounter – condition code error	R	T
F5056	Beneficiary name and insurance number do not match	S	R
G7536	Interrupted stay error	S	T
U0406	Mammography billing error	S	T
U28#1	Date of service occurrence code error	S	T
U28X1	Date of service occurrence code error	S	T
U5200	No Medicare entitlement	S	R
U5211	Services provided after beneficiary’s death	S	T
U5212	Claim submission error	S	T
U5231	Condition code 04 – GHO entitlement error	S	T
U5235	Claim submission error	S	T
U5236	Admission date risk GHO error	R	T
U5241	IME/GME claim during HMO risk period	R	T
U524A-U524G	Participated Centers of Excellence or Provider Partnership Demonstration errors	S	T
U524I	Participated Centers of Excellence or Provider Partnership Demonstration errors	S	T
U5250	United Mine Worker	S	T
U5251	Bill type with invalid condition code	S	T
U5262	GHO Auxiliary record not found	S	R
U5271	Beneficiary is not in risk HMO condition code 78	S	T
U5340	Claim indicates ‘benefits exhausted’	S	T
U5342	Service dates do not match Beneficiary Master record	S	R
U5366	Medicare already paid an exam this month	S	R
U5369	Mammography billing error	S	T
U536A	Pap smear, male beneficiary	S	T
U5373	Mammography billing error	R	S
U5375- U5377	Screening sigmoidoscopy frequency errors	R	S
U5383	Prostrate cancer screening	R	S
U5388	Prostrate cancer screening, invalid sex	R	T
U538B	Screening sigmoidoscopy frequency errors	R	S
U538C	Colorectal screening frequency error	R	S
U538H	Beneficiary incarcerated	S	R
U538J	G0245 or G0246 paid within the last six months	S	R
U538N	More than 10 hours of Medical Nutrition Therapy (MNT)	R	S
U538P	More than 2 hours of follow-up for MNT	R	S
U538R	G0336 can only be paid once in a lifetime	S	D
U538S	Lab code with diagnosis errors	S	R
U538Y	90 day period is past	S	R
U5435	Immunosuppressive drug claim without transplant discharge date	R	S
U5550	Qualifying hospital stay for SNF stay is prior to Part A entitlement	S	R
U5605	ASC billing error	S	R
U5606- U5607	Inpatient bill submission errors	T	S
U5608	Inpatient bill submission errors	S	T
U5612	Screening pap error	R	S
U5613	Duplicate	S	R
U5616	Q0091 billing error	S	T
V8022	Outpatient physical therapy expense limit over applied	S	R
V8024	Occupational therapy expense limit over applied	S	R
W1003	OCE error	S	T
W1445-W1447	MCE bilateral errors	A	S
W1495-W1497	MCE – bilateral errors	A	T
W7010	Non-covered	S	D
W7017	Bilateral error	S	T
W7027	Only incidental services reported	R	S
W7057	E&M condition not met	S	T

J12 MAC Transition(* = off-site link)

J12 MAC Transition
(* = off-site link)