Master Core Curriculum

1. Master Core Curriculum Part A Intermediate Module 2 Reason Code Resolution

2. CMS Centers for Medicare & Medicaid Services RA Remittance Advice UB-92 Uniform Billing Form RTP Return to Provider DDE Direct Data Entry EDI Electronic Data Interchange EMC Electronic Media Claim FI Fiscal Intermediary Acronyms

3. HIPAA Health Insurance Portability and Accountability Act of 1996 ANSI American National Standards Institute EFT Electronic Funds Transfer SPR Standard Paper Remittance ERA Electronic Remittance Advice ASC Accredited Standards Committee FISS Fiscal Intermediary Shared System Acronyms

4. Learning Outcomes At the end of the module, participants will be able to: • describe the difference between rejects and denials • identify reason codes applicable to their situation • determine how to handle the most common return to Provider (RTP) situations

5. Introduction • Reason codes may appear on various forms involved in claim adjudication • Fiscal Intermediary Shared System (FISS) • Return to Provider (RTP) • Remittance Advice

6. Claim Adjudication • Payment • Payment floor • 13 days for HIPAA compliant electronic claims • 25 days for hardcopy and non-HIPAA compliant electronic claims

7. Claim Adjudication • Denial • Denied for medical necessity • Denied for technical medical errors • Denials cannot be corrected but certain denials maybe appealed

8. Claim Adjudication • Rejection • Denied for technical billing errors • Incomplete or invalid information • NO APPEAL RIGHTS • Correct these errors by creating and submitting a new claim that corrected the errors of the rejected claim

9. Claims Correction • A return to provider (RTP) is issued when an incorrect claim is submitted to Medicare that may be corrected because of missing or incorrect information • The FISS status location • TB9997

10. Claims Correction • Perform one of these actions to correct a RTP • write correction on hardcopy RTP and return to Fiscal Intermediary (FI) • correct the error via Direct Data Entry (DDE) • correct the error within the electronic claim and submit a new claim

11. Correct RTP Claims in DDE 11

12. Correct RTP Claims in DDE 12

13. Provider Number Field Tab to the “SEL” Field. Type a “U” or “S” and press [ENTER]. Sort information multiple ways. RTP claims will be in Status & Location T B9997 13

14. RTP reason code is listed in bottom of screen. Press “F1” for definition. Claim Page Number 14

15. The RTP reason code is listed here. Press “F3” to exit and return to claim. A narrative explaining the RTP reason code appears here. 15

16. FISS reason code appears here. The different types of ANSI reason codes appear here. 16

17. Correct RTP Claims in DDE • Any changes made to the screens will not be updated. Press [F9] to update/enter the claim into DDE for reprocessing and payment consideration. If the claim still has errors, reason codes will appear at the bottom of the screen. Continue the correction process until the system takes you back to the Claim Correction Summary. • When the corrected claim has been successfully updated, the claim will disappear from the screen. The following message will display at the bottom of the screen PROCESS COMPLETED - ENTER NEXT DATA.

18. Diagnoses Errors Reason code W0452 The 1st diagnosis code is invalid Reason code W0453 The 2nd diagnosis code is invalid Reason code W0454 The 3rd diagnosis code is invalid Reason Code 11901 HIPAA REQUIRES TYPES OF BILLS 12X AND 22X MUST HAVE AN ADMITTING DIAGNOSIS CODE FOR CLAIMS WITH RECEIPT DATE ON OR AFTER 7/1/04. Common RTPs

19. Common RTPs • Reason code 31300 • THE PAYER CODE MUST BE EQUAL TO A, B, C, D, E, F, G, H, I, L OR Z. CORRECT AND RESUBMIT. A = EGHP E = WC I = VA B = ESRD F = PHS L = LIABILITY C = COND G = LGHP Z = MEDICARE D = AUTO H = BL

20. Common RTPs • Reason code 30715 • The patient last name and/or first initial does not match what was found on the beneficiary's record for this Medicare number • Reason code W7006 • Invalid procedure code

21. Common RTPs • Reason code 12302 • THE SUM OF THE COVERED DAYS CALCULATED PLUS THE NUMBER OF NON-COVERED DAYS CALCULATED MUST EQUAL THE NUMBER OF DAYS BETWEEN THE FROM AND THROUGH DATES IN THE STATEMENT COVERAGE PERIOD. ADD ONE DAY IF THE PATIENT STATUS IS 30. • IF THE ADMIT, FROM AND THROUGH DATES ARE THE SAME, THE PATIENT STATUS IS 02, 03, 05, 50, 51, 61, 62, 63, 71 OR 72 AND CONDITION CODE 40 IS PRESENT (FOR A SAME DAY TRANSFER). THE CLAIM MUST SHOW ONE NON-COVERED DAY AND COVERED CHARGES. • IF THE ADMIT, FROM AND THROUGH DATES ARE THE SAME AND CONDITION CODE 40 IS PRESENT, THE PATIENT STATUS MUST BE 02, 03, 05, 50, 51, 71 OR 72. IF THE PATIENT STATUS IS NOT ONE OF THE LISTED, CONDITION CODE 40 CANNOT BE PRESENT. • IF THE DAY OF DISCHARGE IS THE ONLY DAY TO BE BILLED (ADMIT DATE IS LESS THAN THE FROM DATE, THE FROM AND THROUGH DATES ARE THE SAME AND THE PATIENT STATUS IS NOT 30), SUBMIT AN ADJUSTMENT TO THE PREVIOUS CLAIM TO CORRECT THE DISCHARGE DATE AND PATIENT STATUS. CORRECT AND RESUBMIT.

22. Remittance Advice (RA) Codes • Claim Adjustment Reason Codes • Remittance Advice Remark Codes • Medicare Inpatient Adjudication/Medicare Outpatient Adjudication/Reference Remark Codes

23. Remittance Advice (RA) Codes • Claim Adjustment Reason Codes • Explains the reason for a denied service or partial payment • Standard messages used by all national health payers

24. Remittance Advice (RA) Codes • Group Codes • PR – Patient Responsibility • CO – Contractual Obligation • OA – Other Adjustment • CR – Correction or Reversal of a Prior Decision

25. Remittance Advice (RA) Codes • Remark Codes • Provides information on remittance processing, OR • Gives a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code • Lists standardized generic explanations to help providers understand claims disposition

26. Remittance Advice (RA) Codes • Remark Codes mean: • Denied/Rejected claim • Partial Payment • Reduced Payment • Penalty applied • Additional Payment • Supplement Payment • A list of remark codes are available from • FI bulletins and websites • http://www.wpc-edi.com/codes/asp

27. Remittance Advice (RA) Codes PATIENT NAME PATIENT CNTRL# RC REM DRG# DRG OUT AMT COINSURANCE PAT REFUND CONTRACT ADJ Doe, Jane 11111 CO-16M76 HIC# ICN RC REM OUTCD CAPCD COVD CHGS ESRD NET ADJ PER DIEM RTE FROM DT THRU DT NACHG HICHG TO RC REM PROF COMP MSP PAYMT NCOVD CHGS INTEREST PROC CD AMT CLM STATUS COST COVDY NCOVDY RC REM DRG AMT DEDUCTIBLES DENIED CHGS NET REIMB Group/Reason Code Field RA Remark Codes 27

28. Remittance Advice (RA) Codes • Medicare Inpatient Adjudication/Medicare Outpatient Adjudication/Reference Remark Codes PATIENT NAME PATIENT CNTRL# RC REM DRG# DRG OUT AMT COINSURANCE PAT REFUND CONTRACT ADJ Doe, Jane 11111 MA130 HIC# ICN RC REM OUTCD CAPCD COVD CHGS ESRD NET ADJ PER DIEM RTE FROM DT THRU DT NACHG HICHG TO RC REM PROF COMP MSP PAYMT NCOVD CHGS INTEREST PROC CD AMT CLM STATUS COST COVDY NCOVDY RC REM DRG AMT DEDUCTIBLES DENIED CHGS NET REIMB RA Remark Code – MA130 28

29. Remittance Advice (RA) Codes • Medicare Inpatient Adjudication/Medicare Outpatient Adjudication/Reference Remark Codes PATIENT NAME PATIENT CNTRL# RC REM DRG# DRG OUT AMT COINSURANCE PAT REFUND CONTRACT ADJ Doe, Jane 11111 MA18 HIC# ICN RC REM OUTCD CAPCD COVD CHGS ESRD NET ADJ PER DIEM RTE FROM DT THRU DT NACHG HICHG TO RC REM PROF COMP MSP PAYMT NCOVD CHGS INTEREST PROC CD AMT CLM STATUS COST COVDY NCOVDY RC REM DRG AMT DEDUCTIBLES DENIED CHGS NET REIMB Crossover Information – MA18 29

30. Claim Status Codes 2 4 5 Claim Status Category Codes P3 F2 R3 Health Care Service Decision Codes OR OV OX Insurance Business Process Application Error Codes E025 W025 Provider Taxonomy Codes Additional Remittance Advice Codes

31. Find ANSI Reason Codes in DDE 31

32. Find ANSI Reason Codes in DDE 32

33. List of ANSI reason codes Narrative description of ANSI reason codes 33