|
Topic
|
Category
|
Code
|
Statement
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM01
|
The documentation does not include an initial Certificate of Medical Necessity. Refer to
Medicare Program Integrity Manual 5.3
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM02
|
The initial date on the Certificate of Medical Necessity is after the date of service. Refer to
Medicare Program Integrity Manual 5.3.1
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM03
|
The Certificate of Medical Necessity is missing the beneficiary's name. Refer to
Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM04
|
The Certificate of Medical Necessity is not applicable to this beneficiary. Refer to
Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM05
|
The Certificate of Medical Necessity is missing the treating physician's signature.
Refer to Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM06
|
The Certificate of Medical Necessity is missing the physician's signature date. Refer to
Certificate of Medical Necessity Instructions & Medicare Program Integrity Manual 5.3.1
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM07
|
The Certificate of Medical Necessity was signed by the physician after the claim was
submitted. Refer to Medicare Program Integrity Manual 5.3.1
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM08
|
The Certificate of Medical Necessity contains a physician's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements. Refer to
Medicare Program Integrity Manual 5.3.1
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM09
|
The Certificate of Medical Necessity does not include the item(s) ordered. Refer to Certificate
of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM10
|
The Certificate of Medical Necessity contains a specified length of need that has expired.
Refer to Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM11
|
Section A of the Certificate of Medical Necessity is not properly completed. Refer to
Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM12
|
Section B of the Certificate of Medical Necessity is not properly completed. Refer to
Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM13
|
It is unclear if section B of the Certificate of Medical Necessity was completed by a Physician, non-physician clinician, or a Physician employee. Refer to
Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM14
|
The Certificate of Medical Necessity is not the most current version of the Centers for Medicare & Medicaid Services approved form. Refer to Certificate of Medical Necessity
Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM15
|
The Certificate of Medical Necessity contains an amendment, correction or delayed entry that does not comply with accepted record keeping principles. Refer to Medicare Program Integrity
Manual 3.3.2.5
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM16
|
The delivery date/date of service is not within three months from the initial date of the Certificate of Medical Necessity (CMN) or three months from the date of the physician's
signature. Refer to Medicare Program Integrity Manual 5.3.1.
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM17
|
The Certificate of Medical Necessity is illegible.
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM18
|
The documentation does not contain a valid Initial Certificate of Medical Necessity (CMN). A valid Certificate of Medical Necessity must have sections A-D properly completed. Refer to
Certificate of Medical Necessity Instructions
|
|
GDM
|
INITIAL CMN DENIAL STATEMENTS
|
GDM1Z
|
The Initial Certificate of Medical Necessity contains an error for a reason not otherwise
specified.
|
|
GDM
|
RECERTIFICATION CMN DENIAL STATEMENTS
|
GDN01
|
The documentation does not include a recertification Certificate of Medical Necessity. Refer to Certificate of Medical Necessity Instructions and/or Local Coverage Determination/Policy
Article, as applicable.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO01
|
The documentation does not include a revised Certificate of Medical Necessity. Refer to Certificate of Medical Necessity Instructions and/or Local Coverage Determination/Policy
Article, as applicable.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO02
|
The documentation does not include a revised Certificate of Medical Necessity for a change in the prescribed maximum flow rate. Refer to Certificate of Medical Necessity Instructions,
Local Coverage Determination L33797 and Policy Article A52514.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO03
|
The documentation does not include a revised Certificate of Medical Necessity as the length of need has expired. Refer to Certificate of Medical Necessity Instructions and/or Local
Coverage Determination/Policy Article, as applicable.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO04
|
The documentation does not include a revised Certificate of Medical Necessity for a portable oxygen system added subsequent to an initial stationary system. Refer to Certificate of Medical Necessity Instructions, Local Coverage Determination L33797 and Policy Article
A52514.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO05
|
The documentation does not include a revised Certificate of Medical Necessity for a stationary oxygen system added subsequent to initial portable system. Refer to Certificate of Medical Necessity Instructions, Local Coverage Determination L33797 and Policy Article A52514.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO06
|
The documentation does not include a revised Certificate of Medical Necessity from the new supplier. Refer to Certificate of Medical Necessity Instructions and/or Local Coverage
Determination/Policy Article, as applicable.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO07
|
The documentation does not contain a revised Certificate of Medical Necessity that has been signed and dated by the treating practitioner. Refer to Certificate of Medical Necessity
Instructions and/or Local Coverage Determination/Policy Article, as applicable.
|
|
GDM
|
REVISED CMN DENIAL STATEMENTS
|
GDO1Z
|
The Revised Certificate of Medical Necessity contains an error for a reason not otherwise specified. Refer to Medicare Program Integrity Manual 5.7 and Certificate of Medical
Necessity Instructions.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP01
|
The documentation does not include a detailed written order. Refer to Medicare
Program Integrity Manual 5.2.3 & Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP02
|
The detailed written order is missing the beneficiary's name. Refer to Medicare
Program Integrity Manual 5.2.3 & Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP03
|
The detailed written order is not applicable to this beneficiary. Refer to Medicare Program
Integrity Manual 5.2.1 & Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP04
|
The detailed written order is missing a description of the item. Refer to Medicare Program
Integrity Manual 5.2.3 & Standard Documentation Requirements A55426.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP06
|
The detailed written order is missing the physician/practitioner's signature. Refer to Medicare Program Integrity Manual 5.2.3 & Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP07
|
The detailed written order contains a physician/practitioner's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements. Refer to Medicare Program Integrity Manual 5.2.3 & Medicare Program Integrity Manual 3.3.2.4 &
Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP08
|
The detailed written order is missing the date the physician/practitioner signed the order. Refer
to Medicare Program Integrity Manual 5.2.3 A and Standard Documentation Requirements A55426.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP09
|
The detailed written order is signed by the physician/practitioner after the claim was submitted. Refer to Medicare Program Integrity Manual 5.2.3 and Standard Documentation
Requirements A55426.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP10
|
The detailed written order is missing the date of the order. Refer to Medicare
Program Integrity Manual 5.2.3 & Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP12
|
The documentation does not contain a detailed written order from the transferring supplier or a new order indicating a change of supplier. Refer to Medicare Program Integrity Manual 5.2.7
& Standard Documentation Requirements A55426
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP13
|
The detailed written order contains a treatment frequency of "PRN" or "as needed" that is not
acceptable. Refer to Medicare Program Integrity Manual 5.9
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP15
|
The detailed written order contains an amendment, correction or delayed entry that does not comply with accepted record keeping principles. Refer to Medicare Program Integrity Manual
3.3.2.5
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP16
|
The detailed written order is illegible.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP18
|
The documentation does not include a detailed written order for a change in the item(s)
prescribed. Refer to Medicare Program Integrity Manual 5.2.7
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP19
|
The documentation does not include a detailed written order for a change in the frequency of
use. Refer to Medicare Program Integrity Manual 5.2.7
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP20
|
The documentation does not include a detailed written order for a change in the amount
prescribed. Refer to Medicare Program Integrity Manual 5.2.7
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP21
|
The documentation does not contain a valid detailed written order. Refer to
Medicare Program Integrity Manual 5.2.3
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP22
|
The detailed written order is expired per number of refills.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP23
|
The detailed written order is missing the frequency of use. Refer to Medicare
Program Integrity Manual 5.2.3
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP24
|
The detailed written order is missing the quantity to be dispensed. Refer to Medicare Program
Integrity Manual 5.2.3 and Standard Documentation Requirements A55426.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP25
|
The detailed written order does not contain detailed instructions for use and/or specific amounts to be dispensed. Refer to Medicare Program Integrity Manual 5.2.3 and Standard
Documentation Requirements A55426.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP26
|
The detailed written order is expired per state Pharmacy Law. Refer to Per Survey of Pharmacy Law (nabp.pharmacy/publications-reports/publications/survey-of- pharmacy-law/)
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP27
|
The detailed written order is missing the dosage or concentration. Refer to
Medicare Program Integrity Manual 5.2.3
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP28
|
The detailed written order does not identify the item to be ordered. Refer to Medicare Program
Integrity Manual 5.2.3 and Standard Documentation Requirements A55426.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP29
|
The Certificate of Medical Necessity acting as the written order does not contain a description of the item(s) ordered in Section C. Refer to Medicare Program Integrity Manual 5.2.3 and
5.3.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP30
|
The documentation does not include a detailed written order for replacement equipment.
Refer to Medicare Program Integrity Manual 5.2.7
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP1Z
|
The detailed written order contains an error for a reason not otherwise specified.
|
|
GDM
|
DETAILED WRITTEN ORDERS
|
GDP2Z
|
The Certificate of Medical Necessity acting as the detailed written order contains an error for a
reason not otherwise specified.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR01
|
The documentation does not include a proof of delivery. Refer to Medicare
Program Integrity Manual 4.26 & Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR02
|
The beneficiary or designee signature and date indicating proof of delivery is after the date of
service. Refer to Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR03
|
The beneficiary or designee signature and date indicating proof of delivery is prior to the date of service. Refer to Medicare Program Integrity Manual 4.26.1 and Standard Documentation
Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR04
|
The shipping date indicating proof of delivery is after the date of service. Refer to Medicare Program Integrity Manual 4.26.1 & Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR05
|
The shipping date indicating proof of delivery is prior to the date of service. Refer to Medicare Program Integrity Manual 4.26.1 & Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR06
|
The proof of delivery is missing the beneficiary or designee's signature. Refer to Medicare
Program Integrity Manual 4.26.1 & Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR07
|
The proof of delivery contains a beneficiary or designee's signature that is illegible. Refer to Medicare Program Integrity Manual 4.26.1 & Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR08
|
The proof of delivery is missing the beneficiary's name. Refer to Standard Documentation
Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR09
|
The proof of delivery is missing the delivery address. Refer to Standard Documentation
Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR10
|
The proof of delivery is missing the date delivered. Refer to Medicare Program
Integrity Manual 4.26.1
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR11
|
The proof of delivery is missing the quantity delivered. Refer to Standard Documentation
Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR12
|
The proof of delivery contains a description of contents not consistent with the item(s) billed.
Refer to Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR13
|
The proof of delivery does not contain a sufficiently detailed description of contents. Refer to
Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR14
|
The proof of delivery documentation is missing the date the item(s) was shipped or mailed.
Refer to Medicare Program Integrity Manual 4.26.1 & Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR15
|
The shipping documentation does not contain the delivery service's package identification number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service's records. Refer to Standard Documentation Requirements
A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR16
|
The shipping documentation does not contain proof or confirmation of delivery. Refer to
Standard Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR17
|
The documentation showing proof of delivery for the item(s) billed is prior to Medicare eligibility. Refer to Medicare Program Integrity Manual 4.26.3 and Standard Documentation
Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR18
|
The proof of delivery is illegible.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR19
|
There is no prescription number on any document to compare to the prescription number on the proof of delivery, therefore, the item(s) received cannot be determined. Refer to 42 CFR
424.57(c)(12)
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR20
|
The proof of delivery does not contain a statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item received prior to Medicare
eligibility. Refer to Medicare Program Integrity Manual 4.26.3
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR21
|
The proof of delivery does not contain an attestation from the supplier to the fact that the item meets Medicare requirements. Refer to Medicare Program Integrity Manual 4.26.3 Standard
Documentation Requirements A55426.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR1Z
|
The proof of delivery contains an error for a reason not otherwise specified.
|
|
GDM
|
PROOF of DELIVERY STATEMENTS
|
GDR22
|
The proof of delivery does not contain an attestation from the beneficiary (or beneficiary's designee), that the supplier has examined the item. Refer to Medicare Program Integrity
Manual 4.26.3 and Standard Documentation Requirements A55426.
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS01
|
The documentation does not include a written order prior to delivery for the item(s) specified in the Affordable Care Act 6407. Refer to Social Security Act 1834(a)(11)(B)(i)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS02
|
The written order prior to delivery is missing the physician/practitioner's National Provider
Identifier. Refer to 42 CFR 410.38(g)(4)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS04
|
The written order prior to delivery was signed prior to completion of the face-to- face
examination. Refer to 42 CFR 410.38(g)(3)(i)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS05
|
The written order prior to delivery contains an amendment, correction or delayed entry that
was completed after the date of delivery.
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS06
|
The documentation does not contain a valid written order prior to delivery. Refer to 42 CFR
410.38(g)(4)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS07
|
The written order prior to delivery is missing the beneficiary's name. Refer to 42
CFR 410.38(g)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS08
|
The written order prior to delivery is missing a description of the item. Refer to
42 CFR 410.38(g)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS09
|
The written order prior to delivery does not contain a signature of the prescribing
physician/practitioner. Refer to 42 CFR 410.38(g)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS10
|
The written order prior to delivery is missing the date of the order. Refer to 42
CFR 410.38(g)
|
|
GDM
|
ACA SPECIFIC STATEMENTS
(For claims DOS on or after 1/1/14)
|
GDS11
|
Billing history indicates this item(s) was previously denied for an ACA
requirement, therefore a new supplier must complete the transaction.
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT01
|
There is no documentation showing the beneficiary has nearly exhausted their supplies. Refer
to Medicare Program Integrity Manual 5.2.8
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT02
|
The documentation does not include contact with the beneficiary showing the beneficiary has
nearly exhausted their supplies. Refer to Medicare Program Integrity Manual 5.2.8
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT03
|
The documentation contains a retrospective attestation statement by the supplier or beneficiary
for a refill request. Refer to Standard Documentation Requirements A55426
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT04
|
The refill documentation is missing the beneficiary's name. Refer to Standard Documentation
Requirements A55426
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT05
|
The refill documentation is missing the description of each item that is being requested.
Refer to Standard Documentation Requirements A55426
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT06
|
The refill documentation is missing the date of the refill request. Refer to Standard
Documentation Requirements A55426
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT07
|
The refill documentation is missing information that the beneficiary's remaining supply is approaching exhaustion by the expected delivery date. Refer to Medicare Program Integrity
Manual 5.2.8
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT08
|
The refill documentation is illegible.
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT09
|
The refill documentation indicates the beneficiary has greater than a 10 day supply remaining at the time of delivery of the item(s). Refer to Medicare Program Integrity Manual 5.2.8
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT10
|
The refill documentation indicates contact with the beneficiary occurred greater than 14 days
prior to the date of service. Refer to Medicare Program Integrity Manual 5.2.8
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT11
|
The documentation does not contain a refill request as the delivery slip is not signed by the
beneficiary or designee. Refer to Standard Documentation Requirements A55426
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT13
|
Documentation does not include a valid refill request. Refer to Medicare
Program Integrity Manual 5.2.8
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT14
|
The refill documentation does not indicate the supplier has assessed the functional condition of the supplies being refilled. Refer to Standard Documentation Requirements A55426.
|
|
GDM
|
REFILL REQUIREMENT STATEMENTS
|
GDT1Z
|
The refill documentation contains an error for a reason not otherwise specified.
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU01
|
No medical record documentation was received. Refer to Medicare Program Integrity Manual
3.2.3.8
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU02
|
The medical record documentation is missing the beneficiary's name. Refer to Medicare
Program Integrity Manual 5.7
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU03
|
Some or all of the medical record documentation is not applicable to this beneficiary. Refer to
Medicare Program Integrity Manual 5.7
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU04
|
The medical record documentation is not authenticated (handwritten or electronic) by the
author. Refer to Medicare Program Integrity Manual 3.3.2.4
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU05
|
The medical record documentation contains a practitioner's signature which does not comply
with the Centers for Medicare & Medicaid Services signature requirements. Refer to Medicare Program Integrity Manual 3.3.2.4
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU06
|
The medical record documentation contains an illegible signature and no signature log or
attestation statement was submitted. Refer to Medicare Program Integrity Manual 3.3.2.4
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU07
|
The physicians order, Certificate of Medical Necessity, supplier prepared statement, or the physician's attestation, by itself, does not provide sufficient documentation of medical
necessity. Refer to Medicare Program Integrity Manual 5.7
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU08
|
The medical record documentation does not clearly indicate the date of the amendment,
correction or delayed entry. Refer to Medicare Program Integrity Manual 3.3.2.5
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU09
|
The medical record documentation does not clearly indicate the author of the amendment,
correction or delayed entry. Refer to Medicare Program Integrity Manual 3.3.2.5
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU10
|
The medical record documentation does not clearly identify all original content of the amendment, correction or delayed entry. Refer to Medicare Program Integrity Manual 3.3.2.5
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU11
|
The medical record documentation is dated after the date of service. Refer to Standard
Documentation Requirements A55426
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU12
|
The medical record documentation is illegible.
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU13
|
The documentation was not timely (within the preceding 12 months) to support continued use
by the beneficiary. Refer to Standard Documentation Requirements A55426
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU14
|
The documentation was not timely (within the preceding 12 months) to support continued
need by the beneficiary. Refer to Standard Documentation Requirements A55426
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU15
|
The medical record documentation does not include Medicare approved interactive audio and video telecommunications systems to document the beneficiary's current condition. Refer to
Telehealth - 100-4 Chapter 12 section 190
|
|
GDM
|
MEDICAL RECORDS STATEMENTS
|
GDU1Z
|
The medical record documentation contains an error not otherwise specified.
|
|
GDM
|
UTILIZATION STATEMENTS
|
GDV01
|
The date of service for item(s) billed has been paid. Refer to CMS Manual Pub
100-02 Chapter 15, Section 50.5.1-50.6 &110-140
|
|
GDM
|
UTILIZATION STATEMENTS
|
GDV02
|
The date of service for item(s) billed has paid to another supplier Refer to CMS Manual Pub
100-02 Chapter 15, Section 50.5.1-50.6 &110-140
|
|
GDM
|
UTILIZATION STATEMENTS
|
GDV03
|
The date of service for item(s) billed has been partially paid. Refer to CMS Manual Pub 100-
02 Chapter 15, Section 50.5.1-50.6 &110-140
|
|
GDM
|
UTILIZATION STATEMENTS
|
GDV04
|
The date of service for item(s) billed has been partially paid to another supplier. Refer to CMS
Manual Pub 100-02 Chapter 15, Section 50.5.1-50.6 &110-140
|
|
GDM
|
UTILIZATION STATEMENTS
|
GDV05
|
The claim is billed for greater quantity than the detailed written order indicates. Refer to Medicare Program Integrity Manual 5.9 and applicable Local Coverage Determination/Policy
Article.
|
|
GDM
|
UTILIZATION STATEMENTS
|
GDV06
|
The claim is billed for greater quantity than the proof of delivery indicates. Refer to Medicare
Program Integrity Manual 4.26.1
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW01
|
The beneficiary was not enrolled in Medicare fee for service on the date of service.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW02
|
Claims history indicates same or similar durable medical equipment within the last five years.
Refer to 100-04 Section 50.1
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW03
|
The documentation does not include verification that the equipment was lost, stolen, or
irreparably damaged in a specific incident. Refer to 100-04
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW04
|
The claim was submitted with an incorrect modifier. Refer to Claims Processing Manual &
LCDs
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW05
|
The claim was submitted without a required modifier. Refer to Claims Processing Manual &
LCDs
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW06
|
The documentation submitted indicates the item(s) were returned by the beneficiary.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW07
|
The supplier indicates the item(s) were billed in error.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW08
|
The beneficiary was in an acute care hospital or skilled nursing facility on this date of service.
Refer to Claims Processing Manual
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW09
|
The medical record documentation does not demonstrate a change in the patient's medical
condition necessitating a different item. Refer to Claims Processing Manual & LCDs
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW10
|
The claim submitted is a duplicate to another claim billed.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW11
|
The beneficiary does not reside in this jurisdiction.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW12
|
The claim submitted is a duplicate to another claim processed through medical record review.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW13
|
The date of service on the claim is after the beneficiary's date of death. Refer to
Claims Processing Manual
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW14
|
The time limit for filing claims has expired. Refer to Claims Processing Manual
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW15
|
The claim was billed with an incorrect Medicare Beneficiary Identifier. Refer to Claims
Processing Manual
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW16
|
The item was provided prior to an inpatient hospital admission or Part A covered skilled
nursing facility stay and its use began during the stay.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW17
|
The item was provided during an inpatient hospital or Part A covered skilled nursing facility
stay prior to the day of discharge and the use began during the stay.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW18
|
The payment for this item(s) is included in the payment of another as it bundles.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW19
|
The item billed is not specified in the Product Classification List on the Pricing, Data Analysis
and coding (PDAC) contractor web site. Refer to LCDs of O & P
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW20
|
The claim includes items which are not billable to the DME MAC.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW21
|
The supply or accessory is denied as the base equipment is denied. Refer to applicable Local
Coverage Determination/Policy Article.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW22
|
The documentation submitted is for a Prior Authorization (PA) program that excludes a
Railroad Board (RRB) beneficiary.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW23
(new)
|
The beneficiary resides in a state that is not eligible for Prior Authorization.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW24
(new)
|
This is a duplicate Prior Authorization Request.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW25
(new)
|
An error occurred during the fax transmission of the Prior Authorization request and it is
unable to be processed.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW26
(new)
|
The documentation does not specify the procedure code of the requested item, therefore
elgibility for Prior Authorization cannot be determined.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW27
(new)
|
The requested item is not eligible for Prior Authorization.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW28
(new)
|
The date of the treating physician/practitioner order is prior to the implementation of Prior
Authorization.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW29
(new)
|
The documentation does not include a valid Medicare Beneficiary Identifer (MBI) number.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW30
(new)
|
The documentation does not inlcude a Medicare Beneficiary Identifier (MBI) number.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW31
(new)
|
The documentation demonstrates the requested item has been delivered and is therefore not
eligible for Prior Authorization.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW32
(new)
|
The beneficiary is excluded for Prior Authorization as there is a Representative Payee on file;
therefore, claims billed are not subject to the Prior Authorization program.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW33
(new)
|
The Prior Authorization request has been cancelled per the supplier's request
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW34
(new)
|
The Prior Authorization resubmission does not include all required documentation.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW35
(new)
|
The Prior Authorization submission does not include a beneficiary name.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW36
(new)
|
The Prior Authorization request documenation indicates the beneficiary is deceased.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW37
(new)
|
A previously affirmative determination has been made on the Prior Authorized item requested
for this beneficiary.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW38
(new)
|
The Prior Authorization request coversheet does not include the ordering physician's contact
information.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW39
(new)
|
The Prior Authorization request {Explaination-of-Problem}.
|
|
GDM
|
MISCELLANEOUS STATEMENTS
|
GDW1Z
|
The documentation contains an error not otherwise specified.
|
|
GA
|
DUPLICATES
|
GAA01
|
This is a duplicate of a service already submitted. Refer to Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120-120.3
|
|
GA
|
DUPLICATES
|
GAA02
|
This is a duplicate of a previously submitted claim. Refer to Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120-120.3
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI01
|
Provider did not submit all records requested. Refer to Internet-Only Manuals, Pub 100- 08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e)
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI02
|
Provider did not submit additional records requested. Refer to "Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), Social Security Act 1833(e)
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI03
|
Incomplete/Insufficient information. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e)
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI04
|
The documentation submitted did not support the service(s) billed as being rendered. Refer to Internet-Only Manuals-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI05
|
The documentation submitted did not include a signed physician order or documentation to support intent to order. Refer to Internet-Only Manuals, Pub 100-08, Chapter 3, Section 3.6.2.2 Social Security Act Section 1842(p)(4), Internet-Only Manuals, Pub 100- 08, Chapter 3, Section 3.3.2.4, 42 CFR 410, Internet-Only Manuals 100-02, Chapter 15,
Section 80.6.1
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI06
|
The documentation submitted did not contain an order that was sufficiently specific to support the service. Refer to 42 CFR §410.32(a) (supports diagnostic tests),
§410.32(d)(3) (diagnostic tests), Social Security Act 1862(a)(1)(A), Internet-Only Manuals, 100-02 MBPM Chapter 15, Section 50 (specific to drugs)
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI07
|
The documentation submitted did not support signature requirements were met. Refer to Internet-Only Manuals, Pub 100-08, Chapter 3, Section 3.3.2.4
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI08
|
The documentation submitted was illegible. Refer to Medicare Program Integrity Manual Chapter 3 Section 3.3.2.1
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI09
|
The documentation submitted was for the incorrect service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI10
|
The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI11
|
The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
|
|
GA
|
INSUFFICIENT DOCUMENTATION
|
GAI12
|
The documentation submitted did not include signed documentation to support the medical necessity of the services provided. Refer to Medicare Program Integrity Manual (Pub.100-08) Chapter 3, Section 3.3.2.4, Social Security Act 1862(a)(1)(A)
|
|
GA
|
MEDICAL NECESSITY
|
GAJ01
|
The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3
Section 3.4.1.3
|
|
GA
|
MEDICAL NECESSITY
|
GAJ02
|
Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15
|
|
GA
|
MEDICAL NECESSITY
|
GAJ03
|
The documentation submitted supports the service rendered was for provider/beneficiary comfort or convenience. Refer to 42 CFR 411.15 (j)
|
|
GA
|
MEDICAL NECESSITY
|
GAJ04
|
The documentation submitted does not support the need for this many services or items within this period of time. Refer to Social Security Act 1862(a)(1)(A)
|
|
GA
|
MEDICAL NECESSITY
|
GAJ05
|
The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40
|
|
GA
|
BILLING
|
GAK01
|
The documentation submitted supports an excluded service was billed. Refer to Social Security Act 1862.
|
|
GA
|
BILLING
|
GAK02
|
This claim was recoded to reflect the level of services supported by the documentation submitted. Refer to "Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 Internet-Only Manuals 100-08, Medicare Program Integrity Manual Chapter 6, Sec 6.5.3 (DRG validation)
|
|
GA
|
BILLING
|
GAK03
|
The documentation submitted supports this service is an integral part of another service received on the same day and cannot be billed separately. Refer to Medicare Claims Processing Manual Chapter 23- Section 20.9.2
|
|
GA
|
BILLING
|
GAK04
|
The documentation submitted does not support the number of units billed. Refer to "Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section
3.6.2.4 (coding determinations) and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 (description of HCPCS); AMA CPT Professional coding guidelines
PUB 100-4 Ch. 4 Section 20.4 (UOS), 42 CFR Section 414.40, AMA HCPCS
Professional coding guidelines
|
|
GA
|
BILLING
|
GAK05
|
The documentation submitted does not support the modifier used. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23, PUB 100-4 Ch. 4
Section 20.6 (UOM)
|
|
GA
|
BILLING
|
GAK06
|
This service or procedure is considered investigational and, therefore, not covered by Medicare. Refer to Social Security Act 1862 (a) (1) (A), Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
|
|
GA
|
BILLING
|
GAK07
|
Service denied due to the beneficiary's Medicare benefits having been exhausted. Refer to Internet-Only Manuals, Pub 100-02, MBPM Chapter 5 and Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5 A
|
|
GA
|
BILLING
|
GAK08
|
The claim was changed to reflect the actual service provided. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23
|
|
GA
|
BILLING
|
GAK09
|
Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100- 08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23
|
|
GA
|
BILLING
|
GAK10
|
Documentation supports the service provided was not covered and the beneficiary received a valid Advanced Beneficiary Notice (ABN) of Noncoverage, therefore the beneficiary is liable for charges incurred on this bill. Refer to Internet-Only Manuals 100- 4, Medicare Claims Processing Manual Chapter 30, 100-4 Medicare Claims Processing Manual, Chapter 30
|
|
GA
|
BILLING
|
GAK11
|
Medicare agrees with the provider's determination that the service billed is non-covered. Refer to Internet-Only Manuals 100-4 Medicare Claims Processing Manual, Chapter 30
|
|
GA
|
BILLING
|
GAK12
|
Documentation supports the service provided was not covered, however, the Advanced Beneficiary Notice (ABN) of Noncoverage was invalid, therefore the provider is liable for charges incurred on this bill. Refer to Internet-Only Manuals 100-04, Medicare Claims Processing Manual Chapter 30, 50.6.1
|
|
GA
|
INCOMPLETE/INCORRECT CLAIM INFORMATION
|
GAL01
|
Claim did not contain a valid NPI. Refer to Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70.8.8.6, Section 80.3.1
|
|
GA
|
INCOMPLETE/INCORRECT CLAIM INFORMATION
|
GAL02
|
Documentation supports the provider was ineligible for payment at the time the service was rendered. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual Chapter 3 Section 3.6.2.5 B; 42 CFR § 424.5(a)(2)
|
|
GA
|
INCOMPLETE/INCORRECT CLAIM INFORMATION
|
GAL03
|
Services should have been billed to another contractor. Refer to Medicare Claims Processing Manual Chapter 1 Section 10
|
|
GA
|
CERTIFICATION REQUIREMENTS
|
GAM01
|
The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3
|
|
GA
|
ADMINISTRATIVE
|
GEX01
|
|
|
GA
|
ADMINISTRATIVE
|
GEX02
|
|
|
GA
|
ADMINISTRATIVE
|
GEX03
|
|
|
GA
|
ADMINISTRATIVE
|
GEX04
|
|
|
GA
|
ADMINISTRATIVE
|
GEX05
|
|
|
GA
|
ADMINISTRATIVE
|
GEX06
|
|
|
GA
|
ADMINISTRATIVE
|
GEX07
|
|
|
GA
|
ADMINISTRATIVE
|
GEX08
|
|
|
GA
|
ADMINISTRATIVE
|
GEX09
|
|
|
GA
|
ADMINISTRATIVE
|
GEX10
|
|
|
GA
|
ADMINISTRATIVE
|
GEX11
|
|
|
GA
|
ADMINISTRATIVE
|
GEX12
|
|
|
GA
|
ADMINISTRATIVE
|
GEX13
|
|
|
GA
|
ADMINISTRATIVE
|
GEX14
|
|
|
GA
|
ADMINISTRATIVE
|
GEX15
|
|
|
GA
|
ADMINISTRATIVE
|
GEX16
|
|
|
GA
|
ADMINISTRATIVE
|
GEX17
|
|
|
GA
|
ADMINISTRATIVE
|
GEX18
|
|
|
AMB
|
Insufficient Documentation
|
AMB1A
|
No ambulance run sheet/trip record documentation submitted.
|
|
AMB
|
Insufficient Documentation
|
AMB1B
|
Patient record submitted does not match patient billed on ambulance claim.
|
|
AMB
|
Insufficient Documentation
|
AMB1C
|
Ambulance run sheet/trip record submitted does not match origin/destination
modifier.
|
|
AMB
|
Insufficient Documentation
|
AMB1D
|
The service billed was not documented in the patient medical record for this ambulance transport.
|
|
AMB
|
Insufficient Documentation
|
AMB1E
|
Dispatch status to support service billed was not documented in patient medical record for this service.
|
|
AMB
|
Insufficient Documentation
|
AMB1F
|
No physician certification statement submitted for non-emergency, scheduled, repetitive ambulance service.
|
|
AMB
|
Insufficient Documentation
|
AMB1G
|
Missing documentation to support the beneficiary/representative signature on the ambulance consent.
|
|
AMB
|
Insufficient Documentation
|
AMB1H
|
The service is denied as the beneficiary refused to sign for the transport or consent.
|
|
AMB
|
Insufficient Documentation
|
AMB1I
|
Missing/insufficient or incomplete documentation to support ambulance mileage.
|
|
AMB
|
Insufficient Documentation
|
AMB1Y
|
Patient record submitted does not match the patient on the ambulance PA request.
|
|
AMB
|
Insufficient Documentation
|
AMB1Z
|
Insufficient Documentation (explain identified problem)
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2A
|
Facility to facility transport denied as the documentation supports that the discharging institution was not an appropriate facility.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2B
|
This hospital to hospital transport is denied as the patient was already at a facility able to provide the necessary services.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2C
|
Facility to facility transport denied as the documentation does not support that the receiving institution was the closest facility.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2D
|
Transportation is only covered to the closest facility that can provide the necessary
care.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2E
|
Facility to facility transport denied as documentation indicates transport due to physician and/or beneficiary preference.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2F
|
Facility to facility transport denied as documentation indicates transport due to beneficiary wants to be closer to home or family.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2G
|
Ambulance service to a physician’s office or a physician-directed clinic is not
covered.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2H
|
Ambulance service to a funeral home is not covered.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2I
|
Alternative transport services should have been utilized whether or not they were
available; Beneficiary could have been safely transported by another means of transportation.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2J
|
This service is denied as the beneficiary refused transport.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2K
|
Non-covered charge(s).
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2L
|
Statutorily excluded service(s).
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2M
|
The ambulance service may be covered by the Hospice provider. Please submit to the Hospice provider.
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2N
|
Transport Not Medically Necessary with an Advance Beneficiary Notice (ABN).
|
|
AMB
|
Does not meet definition of Medicare ambulance benefit – Beneficiary Liable
|
AMB2Z
|
Does not meet definition of Medicare ambulance benefit (explain identified
problem)
|
|
AMB
|
Medical necessity – Provider Liable
|
AMB3A
|
Transport Not Medically Necessary without an Advance Beneficiary Notice (ABN).
|
|
AMB
|
Medical necessity – Provider Liable
|
AMB3B
|
Beneficiary death was prior to ambulance dispatch.
|
|
AMB
|
Medical necessity – Provider Liable
|
AMB3C
|
Beneficiary death was after dispatch, before beneficiary loaded onboard ambulance, therefore mileage denied.
|
|
AMB
|
Medical necessity – Provider Liable
|
AMB3Z
|
Medical necessity (explain identified problem)
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4A
|
Missing/incomplete/invalid patient signature or authorized representative signature on ambulance consent.
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4B
|
Missing/Incomplete/Invalid ambulance supplier signature on ambulance record or invalid or no response to signature attestation.
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4C
|
Missing/Incomplete/invalid date on ambulance record.
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4D
|
Missing provider signature on the physician certification statement (non-emergent, scheduled transport).
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4E
|
Incomplete/Invalid provider signature on the physician certification statement (non- emergent, scheduled transport).
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4F
|
Date of service(s) documented on physician certification statement is outside allowed timeframe.
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4G
|
Date of service(s) documented does not match date of service(s) (DOS) billed on ambulance claim.
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4H
|
Incomplete/Invalid/Illegible physician certification statement (non-emergent, scheduled transport).
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4Y
|
Date of service(s) documented does not match date of service(s) (DOS) on ambulance PA request.
|
|
AMB
|
Does not meet benefit (non-clinical)
|
AMB4Z
|
Does not meet non-clinical benefit (explain identified problem)
|
|
AMB
|
Mileage related - Provider Liable
|
AMB5A
|
Payment for ambulance services does not include mileage when the beneficiary is not loaded in the ambulance (ambulance billed services when the beneficiary was not in the ambulance/ambulance billed mileage from their origin rather than the beneficiary's origin/from the ambulance garage).
|
|
AMB
|
Origin/destination related
|
AMB6A
|
Non-payable origin/destination modifiers billed (scheduled service such as physician office to beneficiary's residence).
|
|
AMB
|
Origin/destination related
|
AMB6Y
|
Non-payable origin/destination modifiers in PA request (scheduled service such as physician office to beneficiary's residence).
|
|
AMB
|
Origin/destination related
|
AMB6Z
|
Origin/destination related (explain identified problem)
|
|
AMB
|
Bundling/unbundling
|
AMB7A
|
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated (can only bill for transport &
mileage).
|
|
AMB
|
Bundling/unbundling
|
AMB7Z
|
Bundling/unbundling (explain identified problem)
|
|
AMB
|
Incorrect coding
|
AMB8A
|
Ambulance claim(s) submitted without valid modifier(s).
|
|
AMB
|
Incorrect coding
|
AMB8B
|
Billing provider does not match the rendering provider documented in the medical
records.
|
|
AMB
|
Incorrect coding
|
AMB8C
|
Ambulance claim(s) submitted with invalid modifier(s) combination.
|
|
AMB
|
Incorrect coding
|
AMB8X
|
Ambulance PA request submitted without valid modifier(s).
|
|
AMB
|
Incorrect coding
|
AMB8Y
|
Ambulance PA request submitted with invalid modifier(s) combination.
|
|
AMB
|
Incorrect coding
|
AMB8Z
|
Incorrect coding (explain identified problem)
|
|
AMB
|
Local Coverage Determination (LCD)
|
AMB9A
|
This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.
|
|
AMB
|
Local Coverage Determination (LCD)
|
AMB9B
|
Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.
|
|
AMB
|
Local Coverage Determination (LCD)
|
AMB9Y
|
Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your PA request. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.
|
|
AMB
|
Local Coverage Determination (LCD)
|
AMB9Z
|
Local Coverage Determination (explain identified problem)
|
|
AMB
|
Provider Eligibility
|
AMB0A
|
The Ambulance provider is not approved by Medicare.
|
|
AMB
|
Provider Eligibility
|
AMB0B
|
The Ambulance provider is not eligible for Medicare benefits.
|
|
AMB
|
Provider Eligibility
|
AMB0C
|
The Ambulance provider is not authorized or eligible to bill for BLS services.
|
|
AMB
|
Provider Eligibility
|
AMB0Z
|
Provider Eligibility (explain identified problem)
|
|
AMB
|
Other
|
AM11A
|
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
|
|
AMB
|
Other
|
AM11B
|
This claim was adjusted after records were reviewed and it was determined that the documentation did not support the level of service billed on the claim (i.e., recoding the ambulance service to the level of care that reflects the services rendered, or down coding services when the title of the emergency personnel cannot be validated).
|
|
AMB
|
Other
|
AM11C
|
This claim is a duplicate to another claim.
|
|
AMB
|
Other
|
AM11D
|
Service with no paid base rate in history or no base rate submitted.
|
|
AMB
|
Other
|
AM11W
|
PA request for service not covered by this payer/contractor. You must send the request to the correct payer/contractor.
|
|
AMB
|
Other
|
AM11X
|
This PA request was adjusted after records were reviewed and it was determined that the documentation did not support the level of service requested (i.e., recoding the ambulance service to the level of care that reflects the services rendered, or down coding services when the title of the emergency personnel cannot be validated).
|
|
AMB
|
Other
|
AM11Y
|
This PA request is a duplicate to another request.
|
|
AMB
|
Other
|
AM11Z
|
The documentation (explain identified problem)
|
|
AMB
|
Air Ambulance
|
AM12A
|
The information provided does not support the need for an air ambulance. The approved amount is based on ground ambulance.
|
|
AMB
|
Rejection/Invalid Ambulance Prior Authorization Request
|
AM00A
|
The state where the ambulance company is garaged is not included in the repetitive scheduled non-emergent ambulance transports prior authorization demonstration. States included in the demonstration include New Jersey, Pennsylvania, and South Carolina.
|
|
AMB
|
Rejection/Invalid Ambulance Prior Authorization Request
|
AM00B
|
The codes of the ambulance trip(s) requested are not specific to the repetitive scheduled non-emergent ambulance transports prior authorization demonstration.
|
|
AMB
|
Rejection/Invalid Ambulance Prior Authorization Request
|
AM00Z
|
The ambulance prior authorization request (explain identified problem).
|
|
AMB
|
Affirmed PA response with modifications
|
AM99A
|
PA request was affirmed for fewer trips than requested.
|
|
AMB
|
Affirmed PA response with modifications
|
AM99B
|
PA request was affirmed for fewer days than requested.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1A
|
Documentation does not include history and physical along with any previous treatment (i.e. antibiotic therapy, surgical interventions) for specified condition.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1B
|
The documentation does not include a covered diagnosis per the NCD.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1C
|
Hyperbaric Oxygen (HBO) therapy treatment records not provided or did not include the ascent time, descent time, total compression time, dose of oxygen,
pressurization level, documentation of attendance, and a recording of events.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1D
|
The documentation did not include the diagnostic test that was referenced in the physician narrative to confirm diagnosis.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1E
|
Physician order including number of treatments and/or number of units not provided.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1F
|
Process updates with responds to treatment with measurable signs of healing not provided.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1G
|
Documentation does not indicate the entire body was exposed to oxygen under increased atmospheric pressure.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1H
|
Documentation does not include recent adjunctive therapy.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1I
|
Documentation of diagnostic test and/or labs not provided to support specified condition.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1J
|
Documentation of surgical debridement of devitalized tissue was not provided.
|
|
HBO
|
Insufficient Documentation/General Documentation
|
HBO1K
|
Documentation was not provided indicating the type of treatment or intervention started and/or completed to resolve an active infection.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2A
|
There is no documentation that patient has acute carbon monoxide intoxication.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2B
|
There is no documentation that patient has decompression illness.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2C
|
There is no documentation that patient has a gas embolism.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2D
|
There is no documentation that patient has gas gangrene.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2E
|
There is no documentation that patient has acute traumatic peripheral ischemia.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2F
|
There is no documentation that adjunctive treatment was used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened for acute traumatic peripheral ischemia.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2G
|
There is no documentation of crush injuries and suturing of severed limbs.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2H
|
There is no documentation of adjunctive treatment when loss of function, limb, or life is threatened for crush injuries and suturing of severed limbs.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2I
|
There is no documentation that patient has progressive necrotizing infection (necrotizing fasciitis).
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2J
|
There is no documentation that patient has acute peripheral arterial insufficiency.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2K
|
There is no documentation that patient needs preparation and preservation of compromised skin grafts.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2L
|
There is no documentation that patient has chronic refractory osteomyelitis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2M
|
There is no documentation indicating patient was unresponsive to conventional medical and surgical management for chronic refractory osteomyelitis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2N
|
There is no documentation that patient has osteoradionecrosis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2O
|
There is no documentation that treatment is an adjunct to conventional treatment for osteoradionecrosis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2P
|
There is no documentation that patient has soft tissue radionecrosis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2Q
|
There is no documentation that treatment is an adjunct to conventional treatment for soft tissue radionecrosis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2R
|
There is no documentation that patient has cyanide poisoning.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2S
|
There is no documentation that patient has actinomycosis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2T
|
There is no documentation that treatment is an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment for actinomycosis.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2U
|
There is no documentation patient has both type I or type II diabetes and a lower extremity wound that is due to diabetes.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2V
|
There is no documentation patient has a diabetic wound classified as Wagner grade III or higher.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2W
|
There is no documentation patient has failed an adequate course of standard wound therapy for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2X
|
There is no documentation of initial and repeated wound measurements during 30 days of conservative treatment for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HBO2Y
|
There is no documentation addressing the patient's nutritional status for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AA
|
There is no documentation that a clean, moist bed of granulation tissue with appropriate moist dressing was completed for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AB
|
There is no documentation indicating the patient's vascular status was addressed for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AC
|
There is no documentation indicating optimal glucose control for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AD
|
There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AE
|
There is no documentation indicating the type of treatment or intervention to resolve an active infection has been initiated for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AF
|
There is no documentation indicating debridement of devitalized tissue was completed for diabetic wound management.
|
|
HBO
|
Insufficient Documentation/Specific Conditions
|
HB2AG
|
There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Medical necessity
|
HBO3A
|
Documentation provided indicates less than 30 days of standard wound care treatment was completed for diabetic wound management.
|
|
HBO
|
Medical necessity
|
HBO3B
|
Diagnostic test provided does not confirm the diagnosis.
|
|
HBO
|
Medical necessity
|
HBO3C
|
The documentation for continued use of Hyperbaric Oxygen (HBO) therapy for the identified wound did not show measurable signs of improvement after 30 days of Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Medical necessity
|
HBO3D
|
The documentation did not support the diabetic wound to be a Wagner grade III or higher.
|
|
HBO
|
Medical necessity
|
HBO3E
|
The documentation supports there was measurable signs of healing to the wound with the use of standard wound care prior to the initiation of Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Medical necessity
|
HBO3F
|
Documentation indicates patient's vascular status was compromised but was not addressed.
|
|
HBO
|
Medical necessity
|
HBO3G
|
Documentation indicates patient is at nutritional risk but no education was provided regarding nutrition.
|
|
HBO
|
Medical necessity
|
HBO3H
|
The documentation does not indicate optimal glucose control has been achieved or attempted for diabetic wounds (i.e. medication management to include insulin or oral meds, routine glucose checks ordered).
|
|
HBO
|
Medical necessity
|
HBO3I
|
Documentation indicates an active infection is present and is not being treated.
|
|
HBO
|
Medical necessity
|
HBO3J
|
Documentation indicates there is devitalized tissue in the wound and debridement of this tissue was not completed.
|
|
HBO
|
Medical necessity
|
HBO3K
|
The submitted Diagnosis code(s) does not meet 1 of the 15 Covered Conditions based on the ICD-9/ICD-10 codes approved per Medicare’s National Coverage Determination (NCD) Guidelines.
|
|
HBO
|
Medical necessity
|
HBO3L
|
Documentation indicates patient was not tolerant of Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Medical necessity
|
HBO3M
|
The medical documentation does not support the medical necessity for Hyperbaric Oxygen (HBO) therapy, however, a valid Advance Beneficiary Notice (ABN) was submitted.
|
|
HBO
|
Medical necessity
|
HBO3N
|
The medical documentation does not support the medical necessity for Hyperbaric Oxygen (HBO) therapy, however, an invalid Advance Beneficiary Notice (ABN) was submitted.
|
|
HBO
|
Does not meet benefit
|
HBO4A
|
The electronic medical records are missing the physician's/practitioner's electronic signature and date.
|
|
HBO
|
Does not meet benefit
|
HBO4B
|
The treatment log is missing a valid signature.
|
|
HBO
|
Does not meet benefit
|
HBO4C
|
Documentation submitted was not legible.
|
|
HBO
|
Does not meet benefit
|
HBO4D
|
Documentation indicates a topical application of oxygen was used and this method of administering oxygen does not meet the definition of Hyperbaric Oxygen (HBO) therapy per the National Coverage Determination (NCD).
|
|
HBO
|
Does not meet benefit
|
HBO4E
|
The Hyperbaric Oxygen (HBO) therapy is denied as the documentation indicates
the diagnosis is non-covered, however, a valid Advance Beneficiary Notice (ABN) was submitted.
|
|
HBO
|
Does not meet benefit
|
HBO4F
|
Hyperbaric Oxygen (HBO) therapy is denied as the documentation indicates the diagnosis is non-covered, however, an invalid Advance Beneficiary Notice (ABN) was submitted.
|
|
HBO
|
Hyperbaric Oxygen (HBO) therapy number of billed unit/Incorrect coding MUE
|
HBO5A
|
The number of billed services is denied as it is considered medically unlikely for Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Billing
|
HBO6A
|
Date(s) of service on the documentation do not match the date(s) of service billed on the claim for Hyperbaric Oxygen Therapy.
|
|
HBO
|
Billing
|
HBO6B
|
The documentation indicated that the provider is billing "incident to" the supervising physician, however, the name of the physician is not documented in the medical records.
|
|
HBO
|
Billing
|
HBO6C
|
Claim service not covered by this payer/contractor. You must send claim to the correct payer/contractor.
|
|
HBO
|
Billing
|
HBO6D
|
This is a duplicate claim to another claim.
|
|
HBO
|
Billing
|
HBO6E
|
The medical records submitted do not match the beneficiary billed on the Hyperbaric Oxygen (HBO) therapy claim.
|
|
HBO
|
Billing
|
HBO6F
|
Beneficiary name does not match the Medicare number.
|
|
HBO
|
Billing
|
HBO6G
|
Number of units billed does not match treatment log.
|
|
HBO
|
Incorrect coding
|
HBO7A
|
The provider billed the GA modifier for having a signed Advanced Beneficiary Notice (ABN) on file for services rendered, however, there was no
ABN submitted or the ABN submitted was invalid.
|
|
HBO
|
Order
|
HBO8A
|
Written physician/practitioner signed order not provided for Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Order
|
HBO8B
|
The signature on the physician/practitioner order was illegible and no signature attestation was submitted.
|
|
HBO
|
Order
|
HBO8C
|
Missing valid signature on the physician/practitioner order.
|
|
HBO
|
Order
|
HBO8D
|
Order provided does not indicate number of treatments.
|
|
HBO
|
Order
|
HBO8E
|
Order provided does not have patient name.
|
|
HBO
|
Order
|
HBO8F
|
Order provided is not dated.
|
|
HBO
|
Provider/Beneficiary Eligibility
|
HBO9A
|
Billing provider does not match the rendering provider documented in the medical records.
|
|
HBO
|
Provider/Beneficiary Eligibility
|
HBO9B
|
The supervising provider specialty is not certified to supervise Hyperbaric Oxygen (HBO) therapy.
|
|
HBO
|
Provider/Beneficiary Eligibility
|
HBO9C
|
Beneficiary is not eligible for Medicare Benefits.
|
|
HBO
|
Provider/Beneficiary Eligibility
|
HBO9D
|
The facility is not authorized or eligible to bill Medicare.
|
|
HBO
|
Provider/Beneficiary Eligibility
|
HBO9E
|
The supervising provider is not authorized or eligible to bill Medicare.
|
|
HBO
|
Other
|
HBO0A
|
Documentation received does not support Hyperbaric Oxygen Therapy a letter will be forthcoming with additional information
|
|
HBO
|
Local Coverage Determination (LCD), National Coverage Determination (NCD) and articles for medical review
|
HB11A
|
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1A
|
Documentation does not support the individualized Plan of Care (POC) was completed within 4 days of admission to IRF. Refer to 42 CFR 412.622(a)(4)(iii) as described in paragraph (a)(3)(iv), Medicare Benefit Policy Manual Chapter 1,
Section 110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1B
|
Documentation does not support the Plan of Care (POC) is individualized. Refer to 42 CFR 412.622(a)(4)(iii), Medicare Benefit Policy Manual Chapter 1, Section
110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1C
|
Documentation does not support the individualized Plan of Care (POC) included the estimated length of stay. Refer to Medicare Benefit Policy Manual Chapter 1,
Section 110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1D
|
Documentation does not support the individualized Plan of Care (POC) included the medical prognosis. Refer to Medicare Benefit Policy Manual Chapter 1,
Section 110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1E
|
Documentation does not support the individualized Plan of Care (POC) included the anticipated interventions, functional outcomes and discharge plans. Refer to
Medicare Benefit Policy Manual Chapter 1, Section 110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1F
|
Documentation does not support the individualized Plan of Care (POC) included the expected therapy details i.e. intensity (# hours per day), frequency (# days per week), and duration (total # of days during IRF stay). Refer to Medicare Benefit
Policy Manual Chapter 1, Section 110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1G
|
Documentation does not support the individualized Plan of Care (POC) was completed by the IRF physician. Refer to 42 CFR 412.622(a)(4)(iii) as described in paragraph (a)(3)(iv), Medicare Benefit Policy Manual Chapter 1, Section 110.1.3
|
|
IRF
|
Insufficient Documentation Plan of Care
|
IRF1H
|
The Plan of Care (POC) was not included in the submitted documentation. Refer to
42 CFR 412.622(a)(4)(iii) as described in paragraph (a)(3)(iv), Medicare Benefit Policy Manual Chapter 1, Section 110.1.3
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2A
|
Documentation does not support the preadmission screen was completed or updated within the 48 hours immediately preceding the IRF admission. Refer to 42 CFR 412.622(a)(4)(i)(A), Medicare Benefit Policy Manual Chapter 1, Section
110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2B
|
Documentation does not support the preadmission screen was signed and dated with the rehab physician concurrence of the findings in the preadmission screening. Refer to 42 CFR 412.622(a)(4)(i)(D), Medicare Benefit Policy Manual Chapter 1,
Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2C
|
Documentation does not support the preadmission screen included the patient’s prior level of function. Refer to Medicare Benefit Policy Manual Chapter1, Section
110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2D
|
Documentation does not support the preadmission screen included the patient’s expected length of time to achieve documented expected level of improvement.
Refer to Medicare Benefit Policy Manual Chapter 1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2E
|
Documentation does not support the preadmission screen included the patient’s expected level of improvement. Refer to Medicare Benefit Policy Manual
Chapter1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2F
|
Documentation does not support the preadmission screen included the patient’s anticipated discharge destination from the IRF stay. Refer to Medicare Benefit
Policy Manual Chapter 1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2G
|
Documentation does not support the preadmission screen included the patient’s anticipated post-discharge treatments. Refer to Medicare Benefit Policy Manual
Chapter 1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2H
|
Documentation does not support the preadmission screen included the patient’s risks for clinical complications. Refer to Medicare Benefit Policy Manual Chapter
1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2I
|
Documentation does not support the preadmission screen included the conditions
that caused the need for rehabilitation. Refer to 42 CFR 412.622(a)(4)(i)(B), Medicare Benefit Policy Manual Chapter 1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2J
|
Documentation does not support the preadmission screen included the treatments needed (i.e. physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics). Refer to Medicare Benefit Policy Manual Chapter 1, Section
110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2K
|
Documentation does not support the preadmission screen included the expected frequency and duration of the treatments needed (i.e. physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics). Refer
to Medicare Benefit Policy Manual Chapter 1, Section 110.1.1
|
|
IRF
|
Insufficient Documentation Pre-Admission Screening
|
IRF2L
|
The preadmission screen was not included in the submitted documentation. Refer
to 42 CFR 412.622(a)(4)(i)
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3A
|
The post-admission physician evaluation was not included in the submitted documentation. Refer to 42 CFR 412.622(a)(4)(ii), Medicare Benefit Policy
Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3B
|
The post-admission physician evaluation did not support medical necessity of admission. Refer to Social Security Act 1862(a)(1)(A), Medicare Benefit Policy
Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3C
|
Documentation does not support the post-admission physician evaluation was completed within twenty-four hours of admission to the IRF. Refer to 42 CFR 412.622(a)(4)(ii)(A), Medicare Benefit Policy Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3D
|
The post-admission physician evaluation was completed prior to admission to the IRF. Refer to 42 CFR 412.622(a)(4)(ii)(B), Medicare Benefit Policy Manual
Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3E
|
Documentation does not support the post-admission physician evaluation was performed by a rehabilitation physician. Refer to 42 CFR 412.622(a)(4)(ii)(A),
Medicare Benefit Policy Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3F
|
Documentation did not support the post-admission physician evaluation was dated, timed, and authenticated by the rehabilitation provider. Refer to Medicare Benefit Policy Manual Chapter 1, Section 110.1.2; Medicare Program Integrity Manual
Chapter 3, Section 3.3.2.4
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3G
|
Documentation does not support the post-admission physician evaluation included
a documented history and physical. Refer to Medicare Benefit Policy Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3H
|
Documentation does not support the post-admission physician evaluation included a documented review of the patient's prior and/or current medical and functional conditions/comorbidities. Refer to Medicare Benefit Policy Manual Chapter 1,
Section 110.1.2
|
|
IRF
|
Insufficient Documentation Post-Admission Physician Evaluation
|
IRF3I
|
Documentation does not support that a post-admission physician evaluation was completed to compare the patient’s condition at the preadmission screening and identify any relevant changes since the pre-admission screening. Refer to Medicare
Benefit Policy Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4A
|
Documentation does not support the interdisciplinary team conference (ITC) notes were submitted. Refer to 42 CFR 412.622(a)(5); Social Security Act 1862 (a)(1),
Medicare Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4B
|
Documentation did not consistently support the minimum intensity requirement was met for Interdisciplinary Team Conference (ITC) meetings. Team conferences were not held every 7 days throughout the stay. Refer to 2 CFR 412.622(a)(5)(B);
Medicare Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4C
|
Documentation does not support all required participants attended each interdisciplinary team conference (ITC) throughout the IRF stay. Refer to 42 CFR 412.622(a)(5)(A); Medicare Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4D
|
Documentation does not support that the Interdisciplinary Team Conference (ITC)
held on MM/DD/YY was led by a physician/rehab physician. Refer to 42 CFR 412.622(a)(5)(A); Medicare Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4E
|
Documentation does not support that a licensed or certified treating therapist was present at each team conference. A therapy assistant does not meet the requirement for a certified or registered therapist in attendance. Refer to 42 CFR
412.622(a)(5)(A); Medicare Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4F
|
The team conference had an occupational therapy assistant as the therapist in attendance. A therapy assistant does not meet the requirement for a certified or registered therapist in attendance. Refer to 42 CFR 412.622(a)(5)(A); Medicare
Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Insufficient Documentation Interdisciplinary Team/Conferences
|
IRF4G
|
Documentation does not support the progress towards and/or validity of established goals was assessed during weekly team conferences. Refer to 42 CFR 412.622(a)(5)(B); Medicare Benefit Policy Manual Chapter 1, Section 110.2.5
|
|
IRF
|
Medical Necessity
|
IRF5A
|
Documentation does not support the patient's condition required the close physician supervision, the medical management to support the necessity of an IRF stay. Refer to 42 CFR 412.622(a)(3)(iv), Medicare Benefit Policy Manual Chapter
1, Section 110.2
|
|
IRF
|
Medical Necessity
|
IRF5B
|
Documentation does not support that upon admission to the IRF the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs. Refer to 42 CFR 412.622(a)(3)(i), Medicare Benefit Policy
Manual Chapter 1, Section 110.2
|
|
IRF
|
Medical Necessity
|
IRF5C
|
Documentation does not support that upon admission to the IRF the patient required multiple therapy disciplines (one of which must be physical therapy or occupational therapy). Refer to 42 CFR 412.622(a)(3)(i), Medicare Benefit Policy
Manual Chapter 1, Section 110.2
|
|
IRF
|
Medical Necessity
|
IRF5D
|
Documentation does not support that upon admission to the IRF the patient was expected and/or able to actively participate in an intensive rehabilitation program without compromising the patient’s safety. Refer to 42 CFR 412.622(a)(3)(iii),
Medicare Benefit Policy Manual Chapter 1, Section 110.2
|
|
IRF
|
Medical Necessity
|
IRF5E
|
Documentation does not support that upon admission a measurable improvement that will be of practical value was expected in a reasonable period of time. Refer to 42 CFR 412.622(a)(3)(ii), Medicare Benefit Policy Manual Chapter 1, Section
110.2
|
|
IRF
|
Medical Necessity
|
IRF5F
|
Documentation does not support the patient was sufficiently stable at discharge from the acute care setting to the point the patient would be able to fully participate in the intense rehabilitative treatment provided in the IRF setting. Refer to 42 CFR
412.622(a)(3)(iii), Medicare Benefit Policy Manual Chapter 1, Section 110.2
|
|
IRF
|
Medical Necessity
|
IRF5G
|
Documentation does not support that the intensity requirement for the minimum rehabilitation physician visits were met. The patient must require and receive a minimum of three rehabilitation physician visits each week throughout the stay. The Post-Admission Physician Evaluation (PAPE) counts as one of the rehabilitation physician visits. Refer to 42 CFR 412.622(a)(3)(iv), Medicare
Benefit Policy Manual Chapter 1, Section 110.2
|
|
IRF
|
Order
|
IRF6A
|
Documentation does not support admission orders were written at the time of the patient's admission. Refer to 42 CFR 412.606(a), Medicare Benefit Policy Manual
Chapter 1, Section 110.4
|
|
IRF
|
Order
|
IRF6B
|
Documentation does not support the admission orders were signed, dated. Refer to
Medicare Program Integrity Manual Chapter 3, Section 3.3.2.4
|
|
IRF
|
Billing and/or Coding
|
IRF7A
|
The medical record does not support accuracy of HIPPS code on the claim. Refer
to Medicare Benefit Policy Manual Chapter 1, Section 110.1.5
|
|
IRF
|
Billing and/or Coding
|
IRF7B
|
Documentation does not support the discharge status code as billed on the claim. (Not a denial reason, but rather a correct coding statement). Refer to IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section
140.3.
|
|
IRF
|
Billing and/or Coding
|
IRF7C
|
Required Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF- PAI) not submitted. Refer to 42 CFR 412.604(c), Medicare Benefit Policy Manual
Chapter 1, Section 110.1.5
|
|
IRF
|
Billing and/or Coding
|
IRF7D
|
Documentation does not support that the Patient Assessment Instrument (IRF-PAI) corresponds with the patient’s medical record. Refer to 42 CFR 412.606(c)(2):
Medicare Benefit Policy Manual Chapter 1, Section 110.1.5
|
|
IRF
|
Billing and/or Coding
|
IRF7E
|
Documentation does not support that the patient was discharged from the Inpatient Rehabilitation Facility (IRF) within three days of admission when there were
relevant changes in the patient’s status that deemed the patient to not be an appropriate candidate for IRF level of care. The Health Insurance Prospective Payment System (HIPPS) code was changed to A5001. Refer to Medicare Benefit
Policy Manual Chapter 1, Section 110.1.2
|
|
IRF
|
Medical Necessity – Therapy Services
|
IRF8A
|
Documentation does not support the patient generally requires an intensive rehabilitation therapy program. Refer to 42 CFR 412.622(a)(3), Medicare Benefit
Policy Manual Chapter 1, Section 110.2.2
|
|
IRF
|
Medical Necessity – Therapy Services
|
IRF8B
|
Documentation does not support the patient received intensive rehabilitation
therapy services. Refer to 42 CFR 412.622(a)(3), Medicare Benefit Policy Manual Chapter 1, Section 110.2.2
|
|
IRF
|
Medical Necessity – Therapy Services
|
IRF8D
|
Documentation does not support the treatment plan was monitored and revised as needed to support the consideration of all possible resolutions to any problems
impeding the patient’s progress towards established goals. Refer to 42 CFR
412.622(a)(5)(B), Medicare Benefit Policy Manual Chapter 1, section 110.2.5
|
|
IRF
|
Medical Necessity – Therapy Services
|
IRF8E
|
Physical Therapy (PT)/Occupational Therapy (OT) evaluation/notes were not submitted. Refer to Medicare Benefit Policy Manual, Chapter 15, Section 220.3.,
Social Security Act 1833(e)
|
|
IRF
|
Medical Necessity – Therapy Services
|
IRF8F
|
Documentation did not support one of the therapy disciplines to be either Physical or Occupational therapy. Refer to 42 CFR 412.622(a)(3)(i); Medicare Benefit
Policy Manual Chapter 1, Section 110.2
|
|
IRF
|
Medical Necessity – Therapy Services
|
IRF8G
|
Documentation does not support that therapy services began within thirty-six hours from midnight of the day of admission. Refer to 42 CFR 412.622(a)(3)(ii),
Medicare Benefit Policy Manual Chapter 1, Section 110.2.2
|
|
IRF
|
Administrative
|
IRFXA
|
The file is corrupt and/or cannot be read
|
|
IRF
|
Administrative
|
IRFXB
|
The submission was sent to the incorrect review contractor
|
|
IRF
|
Administrative
|
IRFXC
|
A virus was found
|
|
IRF
|
Administrative
|
IRFXD
|
Other
|
|
IRF
|
Administrative
|
IRFXE
|
The system used to retrieve the Subscriber/Insured details using the given MBI is
temporarily unavailable.
|
|
IRF
|
Administrative
|
IRFXF
|
The documentation submitted is incomplete
|
|
IRF
|
Administrative
|
IRFXG
|
This submission is an unsolicited response
|
|
IRF
|
Administrative
|
IRFXH
|
The documentation submitted cannot be matched to a case/claim
|
|
IRF
|
Administrative
|
IRFXI
|
This is a duplicate of a previously submitted transaction
|
|
IRF
|
Administrative
|
IRFXJ
|
The date(s) of service on the cover sheet received is missing or invalid.
|
|
IRF
|
Administrative
|
IRFXK
|
The NPI on the cover sheet received is missing or invalid.
|
|
IRF
|
Administrative
|
IRFXL
|
The state where services were provided is missing or invalid on the cover sheet
received.
|
|
IRF
|
Administrative
|
IRFXM
|
The Medicare ID on the cover sheet received is missing or invalid.
|
|
IRF
|
Administrative
|
IRFXN
|
The billed amount on the cover sheet received is missing or invalid.
|
|
IRF
|
Administrative
|
IRFXO
|
The contact phone number on the cover sheet received is missing or invalid.
|
|
IRF
|
Administrative
|
IRFXP
|
The Beneficiary name on the cover sheet received is missing or invalid
|
|
IRF
|
Administrative
|
IRFXQ
|
The Claim number on the cover sheet received is missing or invalid
|
|
IRF
|
Administrative
|
IRFXR
|
The ACN on the coversheet received is missing or invalid
|
|
HH
|
Face to Face
|
HH01A
|
The physician certification was invalid since the required face-to-face encounter document (actual clinical note for the face-to face encounter visit for admissions on or after 1/1/15, or the narrative for admissions on or after 4/1/11and before 1/1/15) was missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1 and 30.5.1.2.
|
|
HH
|
Face to Face
|
HH01B
|
The physician certification was invalid since the required face-to-face encounter document was untimely and/or the certifying physician did not document the date of the encounter. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1.2
|
|
HH
|
Face to Face
|
HH01C
|
The physician certification was invalid since the face-to-face encounter was not performed by an approved practitioner. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1.1
|
|
HH
|
Face to Face
|
HH01D
|
The physician certification was invalid since the required face-to-face encounter was not related to the primary reason for home health services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.2
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02A
|
The Plan of Care was missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02B
|
The content of the Plan of Care submitted was insufficient. Refer to CMS IOM
Publication 100-02, Chapter 7, Section 30.2.1
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02C
|
The Plan of Care submitted was not signed. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.3
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02I
|
The Plan of Care submitted was not signed timely by a qualified physician. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.4.
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02D
|
Missing physician certification/recertification. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02E
|
The physician certification/recertification submitted does not support skilled need. Documentation in the certifying physician's medical records and/or the acute/post- acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5 and 42CFR 424.22 (a) and (c).
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02F
|
The physician certification/recertification submitted does not support homebound status. Documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5 and 42CFR 424.22 (a) and (c).
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02G
|
The physician recertification estimate of how much longer skilled services are required is missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.2
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02H
|
The home health agency generated record contained relevant clinical information addressing the “confined to the home” (homebound) eligibility requirement, which was corroborated by the certifying physician or the acute/post-acute facility documentation, but was NOT signed and dated by the certifying physician. Please have the certifying physician sign and date the relevant HHA-generated information and resubmit. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.3.
|
|
HH
|
Plan of Care/Certification/ Recertification
|
HH02J
|
The home health agency generated record contained relevant clinical information addressing the “need for skilled services” eligibility requirement, which was corroborated by the certifying physician or the acute/post-acute facility documentation, but was NOT signed and dated by the certifying physician. Please have the certifying physician sign and date the relevant HHA-generated information and resubmit. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.3.
|
|
HH
|
Confined to the Home: First Criteria
|
HH03A
|
Documentation submitted does not support homebound criteria-one is met. For criteria-one to be met, the patient must either because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walker; the use of special transportation; or the assistance of another person in order to leave their place of residence; or have a condition such that leaving his or her home is medically contraindicated. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.1.1
|
|
HH
|
Confined to the Home: Second Criteria
|
HH04A
|
Documentation submitted does not support a normal inability to leave the home. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.1.1
|
|
HH
|
Confined to the Home: Second Criteria
|
HH04B
|
Documentation submitted does not support a considerable and taxing effort to leave home. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.1.1
|
|
HH
|
Subsequent Episodes
(questions only applicable to subsequent episodes)
|
HH05A
|
The initial Plan of Care was not submitted with the documentation therefore, services on the subsequent episode may not be allowed. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.1
|
|
HH
|
Subsequent Episodes
(questions only applicable to subsequent episodes)
|
HH05B
|
There was no valid initial physician’s certification of patient eligibility therefore; services on the subsequent episode may not be allowed. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.1
|
|
HH
|
Skilled Need
|
HH06A
|
Missing an order for skilled nursing services. Refer to CMS IOM Publication 100-02,
Chapter 7, Section 30.2.2
|
|
HH
|
Skilled Need
|
HH06M
|
An order for skilled nursing services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services, or the frequency of the services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2
|
|
HH
|
Skilled Need
|
HH06B
|
Documentation submitted does not support skilled nursing services are reasonable and necessary. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.1
|
|
HH
|
Skilled Need
|
HH06C
|
Missing an order for physical therapy services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.1
|
|
HH
|
Skilled Need
|
HH06N
|
An order for physical therapy services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2
|
|
HH
|
Skilled Need
|
HH06D
|
Documentation submitted does not include measurable physical therapy treatment goals that are related to the patient’s illness/injury/impairment. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.1
|
|
HH
|
Skilled Need
|
HH06E
|
Documentation submitted does not support physical therapy services are reasonable and necessary and at a level of complexity which requires the skills of a qualified physical therapist. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.2
|
|
HH
|
Skilled Need
|
HH06F
|
Missing an order for speech language pathology services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.1
|
|
HH
|
Skilled Need
|
HH06O
|
An order for speech language pathology services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2
|
|
HH
|
Skilled Need
|
HH06G
|
The documentation for speech language pathology services does not contain specific goals that are measurable. Refer to CMS IOM Publication 100-02, Chapter 7, Section
40.2.1 and 40.2.3
|
|
HH
|
Skilled Need
|
HH06H
|
Documentation submitted does not support speech language pathology services as reasonable and necessary and at a level which requires the skills of a qualified speech therapist. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.3
|
|
HH
|
Skilled Need
|
HH06I
|
Missing an order for occupational therapy services. Refer to CMS IOM Publication 100- 02, Chapter 7, Section 30.2.1
|
|
HH
|
Skilled Need
|
HH06P
|
An order for occupational therapy services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services. Refer to CMS IOM Publication 100-02, Chapter 7, Section
30.2.2
|
|
HH
|
Skilled Need
|
HH06J
|
Occupational therapy visits cannot be allowed without a qualifying service. Refer to CMS IOM Publication 100.02 Chapter 7 Section 30.4
|
|
HH
|
Skilled Need
|
HH06K
|
Documentation submitted does not include specific occupational therapy goals. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.4
|
|
HH
|
Skilled Need
|
HH06L
|
The documentation submitted did not show that the occupational therapy services were reasonable and necessary and at a level of complexity which requires the skills of a qualified occupational therapist. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.4
|
|
HH
|
Dependent Services
|
HH07A
|
Missing an order for the social worker services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.1
|
|
HH
|
Dependent Services
|
HH07G
|
An order for the social worker services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2
|
|
HH
|
Dependent Services
|
HH07B
|
Social worker services cannot be allowed without a qualifying service. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30
|
|
HH
|
Dependent Services
|
HH07C
|
Documentation submitted does not support social worker services are reasonable and necessary. Refer to CMS IOM Publication 100-02, Chapter 7, Section 50.3
|
|
HH
|
Dependent Services
|
HH07D
|
Missing an order for the Home Health Aide Services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.1
|
|
HH
|
Dependent Services
|
HH07H
|
An order for Home Health Aide Services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2
|
|
HH
|
Dependent Services
|
HH07E
|
Home Health Aide services cannot be allowed without a qualifying service. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30
|
|
HH
|
Dependent Services
|
HH07F
|
Documentation submitted does not support home health aides are reasonable and necessary. Refer to CMS IOM Publication 100-02, Chapter 7, Section 50.2
|
|
HH
|
Administrative/Other
(For Transmission via esMD)
|
HH0XA
|
The file is corrupt and/or cannot be read
|
|
HH
|
Administrative/Other
(For Transmission via esMD)
|
HH0XB
|
The submission was sent to the incorrect review contractor
|
|
HH
|
Administrative/Other
(For Transmission via esMD)
|
HH0XC
|
A virus was found
|
|
HH
|
Administrative/Other
(For Transmission via esMD)
|
HH0XD
|
Other
|
|
GB
|
Duplicates
|
GBA01
|
This is a duplicate service previously submitted by the same provider. Refer to IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 1 section 120- 120.3
|
|
GB
|
Duplicates
|
GBA02
|
This is a duplicate service previously submitted by a different provider. Refer to
IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 1 section 120- 120.3
|
|
GB
|
Insufficient Documentation
|
GBB01
|
The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8
|
|
GB
|
Insufficient Documentation
|
GBB02
|
The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C
|
|
GB
|
Insufficient Documentation
|
GBB03
|
The documentation submitted does not support services were rendered as billed.
Refer to IOM-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A
|
|
GB
|
Insufficient Documentation
|
GBB04
|
The documentation submitted did not include a physician order. Refer to IOM, Pub 100-08, Chapter 3, Section 3.6.2.2
|
|
GB
|
Insufficient Documentation
|
GBB05
|
The documentation submitted was missing patient identifiers. Refer to Standards for Adequacy of Medical Records; Section 1833 (e), Title XVIII, of the Social Security Act.
|
|
GB
|
Insufficient Documentation
|
GBB06
|
The documentation submitted was for the incorrect date of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
|
|
GB
|
Insufficient Documentation
|
GBB07
|
The documentation submitted does not support the modifiers billed. Refer to Medicare Program Integrity Manual Chapter 3, IOM Pub 100-04, Medicare
Claims Processing Manual Chapter 1
|
|
GB
|
Insufficient Documentation
|
GBB08
|
The ABN is invalid, incomplete or missing. Refer to Medicare Claims Processing Manual Chapter 30, Section 40.3.6
|
|
GB
|
Insufficient Documentation
|
GBB09
|
The documentation submitted was for the incorrect beneficiary. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8
|
|
GB
|
Insufficient Documentation
|
GBB10
|
The documentation submitted is not legible. Refer to Medicare Program Integrity Manual, Chapter 3 Section 3.3.2.1
|
|
GB
|
Insufficient Documentation
|
GBB11
|
The documentation submitted does not support the number of units billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23
|
|
DMEPOS
|
7-element Order
|
PMD1A
|
The documentation does not include a 7-element order. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article
A55426
|
|
DMEPOS
|
7-element Order
|
PMD1B
|
The 7-element order includes elements that are illegible. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article
A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1D
|
The 7-element order does not include the beneficiary's name. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article
A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1E
|
The 7-element order contains an incorrect beneficiary's name. Refer to 42 Code of Federal
Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1F
|
The 7-element order does not include a valid description of the item. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage
Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1G
|
The 7-element order does not include the date of the face-to-face examination. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local
Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1H
|
The 7-element order does not include a valid face-to-face date. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article
A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1I
|
The 7-element order does not include pertinent diagnosis/condition(s) that are
directly related to the need for the power mobility device. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1J
|
The 7-element order does not include the length of need. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article
A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1K
|
The 7-element order does not include the physician/practitioner's signature. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local
Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1L
|
The 7-element order contains a physician/practitioner's signature which does not comply with the CMS signature requirements. Refer to Program Integrity Manual 3.3.2.4 & Local
Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1M
|
The 7-element order does not include the date the physician/practitioner signed the order.
Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1N
|
The 7-element order contains an invalid physician/practitioner's signature date. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local
Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1O
|
The supplier did not receive a valid copy of the 7-element order within 45 days after the completion of the face-to-face examination. Refer to 42 Code of Federal Regulations 410.38
(c), Local Coverage Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1P
|
The 7-element order is dated prior to the completion of the face-to-face requirements. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage
Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1Q
|
It is undetermined who completed one or more elements on the 7-element order. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local
Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1T
|
The ordering physician is a Podiatrist (DPM) or Chiropractor (DC). Refer to Local Coverage
Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1U
|
The 7-element order contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles. Refer to Medicare Program Integrity Manual
3.3.2.5.
|
|
DMEPOS
|
7-element Order
|
PMD1V
|
The 7-element order does not contain a valid date stamp (or equivalent) to document the receipt date of the order by the supplier. Refer to Local Coverage
Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1W
|
The 7-element order does not contain a date stamp (or equivalent) to document the receipt date of the order by the supplier. Refer to Local Coverage Determination 33789 & Local
Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1X
|
The 7-element order was not written by the same physician/practitioner who
completed the face-to-face examination. Refer to Refer to 42 Code of Federal Regulations
410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local Coverage Article A55426.
|
|
DMEPOS
|
7-element Order
|
PMD1Z
|
The 7- element order (explain identified problem with the 7-element order).
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2A
|
The documentation does not include a face-to-face examination. Refer to 42 Code of Federal Regulations 410.38, Medicare Program Integrity Manual 5.9.2, Local Coverage Determination
33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2B
|
The face-to-face examination does not contain a valid date stamp (or equivalent) to document the receipt date of the examination by the supplier. Refer to 42 Code of Federal Regulations
410.38 (c), Local Coverage Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2C
|
The face-to-face examination does not clearly indicate that a major reason for the visit was a mobility evaluation. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage
Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2D
|
The face-to-face examination does not paint a clear picture of the beneficiary's
functional abilities and limitations as it does not contain sufficient objective data. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2E
|
Claim history demonstrates the beneficiary received a similar power mobility
device within the past five years. The documentation does not demonstrate a change in medical condition that meets the medical necessity for the requested base. Refer to Medicare Benefit Policy Manual 100-02 Chapter 15, Section 110.2.C & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2F
|
Claim history demonstrates the beneficiary received same or similar durable
medical equipment. The documentation does not indicate the rationale for the power mobility device requested. Refer to Medicare Benefit Policy Manual 100-02 Chapter 15, Section
110.2.C & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2H
|
The medical documentation demonstrates the beneficiary's primary need for the power mobility device is for use outside of the home. Refer to 42 Code of Federal Regulations
410.38 (a), Medicare Program Integrity Manual 5.9.2 & Local Coverage Determination 33789.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2J
|
The face-to-face examination contains conflicting information. Refer to Local Coverage
Determination 33789.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2K
|
The face-to-face examination was completed on a limited space template with insufficiently detailed or incomplete narrative to support medical necessity from the physician/practitioner. Refer to 42 Code of Federal Regulations 410.38 (c) & Medicare
Program Integrity Manual 3.3.2.1.1.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2N
|
The supplier did not receive the face-to-face examination within 45 days after the completion date. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage Determination
33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2O
|
The face-to-face examination contains amendments, corrections, and/or delayed entries that do
not comply with accepted record keeping principles. Refer to Medicare Program Integrity Manual 3.3.2.5.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2P
|
The face-to-face examination contains a physician/practitioner's signature which does not comply with the CMS signature requirements. Refer to Program Integrity Manual 3.3.2.4 &
Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2Q
|
The face-to-face examination was not signed by the physician/practitioner. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4 & Local
Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2R
|
The 120 days allowed to deliver the power mobility device following completion of the face- to-face examination has been exceeded. Refer to Local Coverage Determination 33789.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2S
|
The face-to-face documentation is illegible.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2U
|
The face-to-face examination does not contain a date stamp (or equivalent) to
document the receipt date of the examination by the supplier. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage Determination 33789 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2V
|
The face-to-face documentation does not contain the beneficiary's name. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage Determination 33789 & Local Coverage
Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2W
|
The face-to-face examination does not include the encounter date. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage Determination 33789 & Local Coverage Article
A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2X
|
The face-to-face examination is incomplete as it is missing pages. Refer to 42 Code of Federal Regulations 410.38 (c), Local Coverage Determination 33789 & Local Coverage Article
A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2Y
|
The documentation does not demonstrate the beneficiary's power mobility device was lost, stolen or irreparably damaged in a specific incident. Refer to Medicare Benefit Policy Manual
100-02 Chapter 15, Section 110.2.C & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PM2AA
|
Supplier-produced records, even if signed by the ordering physician/practitioner and
attestation letters are deemed not to be part of a medical record for Medicare payment purposes. Refer to Medicare Program Integrity Manual 5.7 & Local Coverage Article A55426.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PM2AB
|
The addendum to the face-to-face examination was not completed by the treating
physician/practitioner. Refer to Medicare Program Integrity Manual 3.3.2.5.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PM2AC
|
The medical documentation contains conflicting information. Refer to Local Coverage
Determination 33789.
|
|
DMEPOS
|
General Face to Face Exam/Medical Records
|
PMD2Z
|
The face-to-face examination (explain identified problem with the face to face)
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3A
|
The face-to-face examination does not demonstrate how mobility limitations significantly impair the beneficiary's ability to participate in one or more mobility- related activities of daily living (MRADLs) in the home. Refer to Local Coverage Determination
33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3B
|
The face-to-face examination does not demonstrate the beneficiary's mobility
limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3C
|
The face-to-face examination does not demonstrate the beneficiary's upper
extremity function is insufficient to self-propel an optimally-configured manual wheelchair in the home. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3D
|
The face-to-face examination does not demonstrate the beneficiary is able to safely transfer to and from the power operated vehicle. Refer to Local Coverage Determination 33789 Policy
Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3E
|
The face-to-face examination does not demonstrate the beneficiary is able to
operate the tiller steering system of the power operated vehicle. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3F
|
The face-to-face examination does not demonstrate the beneficiary is able to
maintain postural stability and position while operating the power operated vehicle. Refer to Local Coverage Determination 33789.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3G
|
The face-to-face examination identifies a physical deficit that may prevent the safe use of the power mobility device. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3H
|
The beneficiary's weight does not meet the weight capacity for the power mobility device
requested. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3I
|
The face-to-face examination does not demonstrate the use of the power mobility device will
significantly improve the beneficiary's ability to participate in mobility related activities of daily living (MRADLs). Refer to Local Coverage Determination 33789 Policy Article
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3J
|
The face-to-face examination demonstrates the beneficiary expressed an unwillingness to use the power mobility device in the home. Refer to Local Coverage
Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3K
|
The face-to-face examination does not demonstrate the beneficiary has the mental capability to safely operate the power mobility device. Refer to Local Coverage Determination 33789
Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3L
|
The face-to-face examination does not demonstrate a caregiver is unable to
adequately propel an optimally configured manual wheelchair. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3M
|
The face to face examination does not demonstrate the caregiver is available,
willing and able to safely operate the power mobility device requested. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3N
|
The face-to-face examination does not demonstrate the use of a power operated vehicle has
been excluded. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3S
|
The documentation does not demonstrate the beneficiary uses a ventilator which is mounted
on the power mobility device. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3T
|
The documentation does not demonstrate the beneficiary's mobility limitations are due to a neurological condition, myopathy, or congenital skeletal deformity. Refer to Local Coverage
Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3U
|
The documentation does not demonstrate the beneficiary is expected to grow in height. Refer
to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3V
|
The documentation does not provide sufficient information to demonstrate why the home does not provide adequate access between rooms, maneuvering space and surfaces for the power operated vehicle. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3W
|
The documentation does not demonstrate the beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick and the system is being used on the power mobility device. Refer to Local Coverage Determination 33789 Policy Article
A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3X
|
The documentation does not demonstrate the beneficiary meets the coverage criteria for a
power tilt seating system and the system is being used on the power mobility device. Refer to Local Coverage Determination 33789 and Policy Article A52498
|
|
DMEPOS
|
LCD Criteria Specific
|
PMD3Z
|
The documentation in the face-to-face examination (explain identified problem with the documentation related to specific criteria in the LCD). Refer to Local Coverage Determination
33789 and Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AA
|
The documentation does not demonstrate the beneficiary meets the coverage criteria for a power tilt and power recline seating system and the system is being used on the power mobility device. Refer to Local Coverage Determination 33789 and Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AB
|
The documentation does not demonstrate the beneficiary meets the coverage criteria for a power recline seating system and the system is being used on the power mobility device. Refer
to Local Coverage Determination 33789 and Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AC
|
The documentation demonstrates the beneficiary meets coverage criteria for a skin protection seat or back cushion which is not appropriate with a Captain's Chair. Refer to Local Coverage
Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AD
|
The documentation demonstrates the beneficiary meets coverage criteria for a
positioning seat or back cushion which is not appropriate with a Captain's Chair. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AE
|
The documentation demonstrates the beneficiary does not have special skin
protection or positioning needs to support a sling/solid seat/back wheelchair. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AF
|
The documentation does not demonstrate the beneficiary's neurological deficits significantly impact the beneficiary's mobility limitations. Refer to Local Coverage Determination 33789
Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AH
|
The documentation demonstrates the length of need for the power mobility device is less than 3 months and the underlying condition is reversible. Refer to Local Coverage Determination
33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AI
|
The documentation is not considered timely as it is not dated within the preceding 12 months.
Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCD Criteria Specific
|
PM3AJ
|
The medical record does not contain the beneficiary's weight. Refer to Local Coverage
Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4A
|
The documentation does not include a detailed product description. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426 & Local Coverage
Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4B
|
The detailed product description does not include the beneficiary's name.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4C
|
The detailed product description contains an incorrect beneficiary's name. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426. & Local Coverage
Determination 33789 Policy Article A52498
|
|
DMEPOS
|
Detailed Product Description
|
PMD4D
|
The detailed product description does not include the physician/practitioner's
identification information. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426 & Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4E
|
The detailed product description contains incorrect physician/practitioner's
identification information. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426 & Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4F
|
The detailed product description is illegible. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426 & Local Coverage Determination 33789 Policy Article
A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4H
|
The detailed product description contains insufficient detail to properly identify the item(s) to be dispensed in order to determine they are properly coded. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426 & Local Coverage Determination
33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4I
|
The detailed product description contains a physician/practitioner's signature which does not comply with the CMS signature requirements. Refer to Program Integrity Manual 3.3.2.4, Local Coverage Article A55426 & Local Coverage Determination 33789, Policy Article
A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4J
|
The detailed product description signature date of the ordering physician/practitioner is incomplete or invalid. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage
Article A55426 & Local Coverage Determination 33789 Policy Article A52498
|
|
DMEPOS
|
Detailed Product Description
|
PMD4K
|
The detailed product description does not contain a valid date stamp (or equivalent) documenting the receipt date by the supplier. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426 & Local Coverage Determination 33789 Policy Article
A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4L
|
The detailed product description is invalid as it was prepared prior to completion of the 7- element order. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article
A55426 & Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4M
|
The detailed product description contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles. Refer to Medicare Program Integrity Manual 3.3.2.5, Local Coverage Article A55426 & Local Coverage Determination 33789
Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4N
|
The detailed product description contains a Healthcare Common Procedure Coding System (HCPCS) code that is not consistent with the narrative description of the power mobility device as assigned by the Medicare Pricing, Data Analysis, and Coding (PDAC) contractor. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local
Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4O
|
The detailed product description contains a power mobility device that has not been coded by the Medicare Pricing, Data Analysis, and Coding (PDAC) contractor at the time of the request. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local
Coverage Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4P
|
The detailed product description was not signed by the physician/practitioner. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local Coverage
Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4Q
|
The detailed product description is not dated by the ordering physician/practitioner. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local Coverage
Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4R
|
The detailed product description does not contain a date stamp (or equivalent) documenting the receipt date by the supplier. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local Coverage Determination 33789; Policy
Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4T
|
The detailed product description is invalid as it was prepared prior to the completion of the face-to-face examination. Refer to Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local Coverage Determination; 33789 Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4U
|
The detailed product description was signed prior to the amendments, corrections and/or delayed entries to the 7-element order. Refer to Medicare Program Integrity Manual 3.3.2.5, Local Coverage Article A55426, & Local Coverage Determination 33789 Policy Article
A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4V
|
The detailed product description was not completed by the same practitioner who completed the face to face and the 7EO. Refer to 42 Code of Federal Regulations 410.38 (c), Medicare Program Integrity Manual 5.2.4, Local Coverage Article A55426, & Local Coverage
Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
Detailed Product Description
|
PMD4Z
|
The detailed product description (explain identified problem with the DPD)
|
|
DMEPOS
|
Supporting Medical Documentation
|
PMD5A
|
The supporting medical documentation received was illegible.
|
|
DMEPOS
|
Supporting Medical Documentation
|
PMD5C
|
The supporting medical documentation does not include a physician/practitioner's signature.
Refer to Medicare Program Integrity Manual 3.3.2.4.
|
|
DMEPOS
|
Supporting Medical Documentation
|
PMD5D
|
The supporting medical documentation contains an illegible signature. Refer to Medicare
Program Integrity Manual 3.3.2.4.
|
|
DMEPOS
|
Supporting Medical Documentation
|
PMD5E
|
The supporting medical documentation contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles. Refer to Medicare
Program Integrity Manual 3.3.2.5.
|
|
DMEPOS
|
Supporting Medical Documentation
|
PMD5F
|
The supporting medical documentation contains a physician/practitioner's signature that does not comply with the CMS signature requirements. Refer to Medicare Program Integrity
Manual 3.3.2.4.
|
|
DMEPOS
|
Supporting Medical Documentation
|
PMD5Z
|
The supporting medical documentation (explain identified problem)
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6A
|
The documentation does not demonstrate the supplier's Assistive Technology
Professional has a current Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certification. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6B
|
The documentation does not demonstrate a Rehabilitation Engineering and
Assistive Technology Society of North America (RESNA) certified professional had direct in- person involvement in the selection of the power mobility device. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6C
|
The Assistive Technology Professional documentation contains amendments,
corrections, and/or delayed entries that do not comply with accepted record keeping principles. Refer to Medicare Program Integrity Manual 3.3.2.5.
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6D
|
The Assistive Technology Professional documentation does not include a signature. Refer to
Medicare Program Integrity Manual 3.3.2.4.
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6E
|
The Assistive Technology Professional's Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certification has expired. Refer to Local Coverage
Determination 33789 Policy Article A52498
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6F
|
The Assistive Technology Professional documentation does not include a date of service.
Refer to Local Coverage Determination 33789 Policy Article A52498
|
|
DMEPOS
|
Assistive Technology Professional
|
PMD6Z
|
The Assistive Technology Professional documentation (explain identified problem)
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7A
|
The financial attestation is not signed by the supplier or licensed/certified medical professional (LCMP). Refer to Local Coverage Determination 33789 Policy Article A52498
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7B
|
The documentation does not include a financial attestation stating the
licensed/certified medical professional (LCMP) has no financial relationship with the supplier. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7C
|
The specialty evaluation completed by the licensed/certified medical professional (LCMP) does not have evidence of concurrence or disagreement by the treating physician/practitioner. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7D
|
The licensed/certified medical professional (LCMP) mobility examination does not have evidence of concurrence or disagreement by the treating physician/practitioner. Refer to Local
Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7F
|
The specialty evaluation by the licensed/certified medical professional (LCMP)
contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles. Refer to Medicare Program Integrity Manual 3.3.2.5.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7G
|
The specialty evaluation is illegible.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7I
|
The specialty evaluation contains a signature which does not comply with the CMS signature
requirements. Refer to Medicare Program Integrity Manual 3.3.2.4.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7J
|
The financial attestation is not dated. Refer to Local Coverage Determination 33789 Policy
Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7K
|
The financial attestation statement submitted does not contain the name of the licensed/certified medical professional (LCMP) who completed the specialty evaluation.
Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7L
|
The financial attestation statement submitted does not contain the name of the licensed/certified medical professional (LCMP) who completed the mobility examination.
Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7M
|
The licensed/certified medical professional (LCMP) mobility examination contains amendments, corrections, and/or delayed entries that do not comply with accepted record
keeping principles. Refer to Medicare Program Integrity Manual 3.3.2.5.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7N
|
The licensed/certified medical professional (LCMP) mobility examination is
illegible.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7O
|
The licensed/certified medical professional (LCMP) mobility examination does not comply with the CMS signature requirements. Refer to Medicare Program Integrity Manual 3.3.2.4.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7P
|
The specialty evaluation was not signed by the licensed/certified medical
professional (LCMP). Refer to Local Coverage Determination 33789; Policy Article A52498 & Program Integrity Manual 3.3.2.4
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7Q
|
The licensed/certified medical professional (LCMP) mobility examination was not signed by the LCMP. Refer to Local Coverage Determination 33789; Policy Article A52498 & Program
Integrity Manual 3.3.2.4
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7R
|
The specialty evaluation does not contain a date of service. Refer to Local Coverage
Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7S
|
The licensed/certified medical professional (LCMP) mobility examination does not contain a
date of service. Refer to Local Coverage Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7T
|
The specialty evaluation does not include the treating physician/practitioner's
signature date. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7U
|
The licensed/certified medical professional (LCMP) mobility examination does not include the date of concurrence. Refer to Local Coverage Determination 33789 Policy Article
A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7V
|
The specialty evaluation does not contain a valid date stamp (or equivalent) to document the receipt date of the examination by the supplier. Refer to Local Program
Integrity Manual 5.9.2, 42 Code of Federal Regulations 410.38 (c) , Local Coverage Article
A55426, Coverage Determination 33789 & LCD A55426
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7W
|
The specialty evaluation does not contain a date stamp (or equivalent) to document the receipt date of the examination by the supplier. Refer to Local Program Integrity Manual 5.9.2, 42 Code of Federal Regulations 410.38 (c) , Local Coverage Article A55426, Coverage
Determination 33789 & LCD A55426
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7X
|
The specialty evaluation contains conflicting information. Refer to Local Coverage
Determination 33789; Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7Y
|
The licensed/certified medical professional (LCMP) mobility examination has
been completed on a limited space template with insufficiently detailed or incomplete narrative to support medical necessity from the physician/practitioner. Refer to 42 Code of Federal Regulations 410.38 (c) & Medicare Program Integrity Manual 3.3.2.1.1.
|
|
DMEPOS
|
LCMP/PT/OT
|
PMD7Z
|
The licensed/certified medical professional (LCMP) (explain identified problem)
|
|
DMEPOS
|
LCMP/PT/OT
|
PM7AA
|
The specialty evaluation does not document the medical necessity for the power mobility device and its special features. Refer to Local Coverage Determination 33789 Policy Article
A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PM7AB
|
The documentation does not include a specialty evaluation completed by the licensed/certified medical professional (LCMP). Refer to Local Coverage Determination
33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PM7AC
|
The documentation does not include a mobility examination completed by the licensed/certified medical professional (LCMP). Refer to Local Coverage Determination
33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PM7AD
|
The licensed/certified medical professional (LCMP) documentation contains conflicting
information. Refer to Local Coverage Determination 33789 Policy Article A52498.
|
|
DMEPOS
|
LCMP/PT/OT
|
PM7AE
|
The specialty evaluation has been completed on a limited space template with insufficiently detailed or incomplete narrative to support medical necessity from the physician/practitioner. Refer to 42 Code of Federal Regulations 410.38 (c) & Medicare Program Integrity Manual
3.3.2.1.1.
|
|
DMEPOS
|
Other
|
PMD8A
|
An affirmative decision was made on a previously submitted Prior Authorization
request for this beneficiary.
|
|
DMEPOS
|
Other
|
PMD8B
|
No determination letter was sent to the supplier due to insufficient identification
information.
|
|
DMEPOS
|
Other
|
PMD8C
|
No determination letter was sent to the treating physician/practitioner due to
insufficient identification information.
|
|
DMEPOS
|
Other
|
PMD8D
|
No determination letter was sent to the beneficiary due to insufficient identification
information.
|
|
DMEPOS
|
Other
|
PMD8Z
|
The documentation (explain identified problem)
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9A
|
The beneficiary does not reside in this jurisdiction. Please resubmit your request to Jurisdiction-A at Noridian Healthcare Solutions, Attn: DME-MR PAR, PO BOX
6742, Fargo ND 58108-6742 or fax to 701-277-7891.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9B
|
The beneficiary does not reside in this jurisdiction. Please resubmit your request to
Jurisdiction-B at CGS-DME Medical Review-Prior Authorization, P.O. Box 23110, Nashville, TN 37202-4890 or fax to 615-660-5992.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9C
|
The beneficiary does not reside in this jurisdiction. Please resubmit your request to Jurisdiction-C at CGS-DME Medical Review-Prior Authorization, P.O. Box
24890, Nashville, TN 37202-4890 or fax to 615-664-5960.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9D
|
The beneficiary does not reside in this jurisdiction. Please resubmit your request to Jurisdiction-D at Noridian Healthcare Solutions, Attn: DME-MR PAR, PO BOX
6742, Fargo ND 58108-6742 or fax to 701-277-7891.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9H
|
The documentation does not specify the procedure code of the power mobility
device requested, therefore eligibility for Prior Authorization cannot be determined.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9I
|
The base code of the power mobility device requested is not a code that is eligible
for Prior Authorization.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9M
|
The documentation demonstrates the power mobility device has been delivered and is
therefore not eligible for Prior Authorization.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9N
|
The beneficiary is excluded from Prior Authorization as there is a Representative
Payee on file; therefore, claims billed are not subject to the reduction in payment.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9O
|
This beneficiary is not subject to Prior Authorization due to having a Representative Payee on file; however, the HCPCS code is eligible for Advanced
Determination of Medicare Coverage review.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9P
|
The procedure code is not subject to Prior Authorization; however, it is eligible for
Advanced Determination of Medicare Coverage.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9U
|
A previously affirmative determination has been made on this wheelchair base for
this beneficiary.
|
|
DMEPOS
|
Rejection/Invalid PAR
|
PMD9Z
|
The Prior Authorization request (explain identified problem)
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS001
|
The medical record does not indicate any pressure ulcers on the trunk or pelvis. Refer to Local
Coverage Determination 33642 and Policy Article 52490
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS002
|
The medical record documentation does not indicate the beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis. Refer to Local Coverage Determination L33642
and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS003
|
The medical record does not demonstrate the beneficiary was on a comprehensive ulcer treatment program for at least a month prior to being placed on a group 2 surface. Refer to
Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS004
|
Medical record documentation does not demonstrate the staged ulcer(s) have failed to improve over the past month. Refer to Local Coverage Determination L33642 and Policy Article
A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS005
|
The medical record documentation does not demonstrate the beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis. Refer to Local Coverage Determination
L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS006
|
The medical record documentation does not demonstrate the beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. Refer to
Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS007
|
The medical record documentation does not demonstrate the beneficiary has been on a group II or III support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days. Refer to Local Coverage Determination L33642 and Policy Article
A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS008
|
The medical record document demonstrates that it has been more than 60 days from the date of the mycocutaneous flap or skin graft surgery, and fails to explain the continued medical
need for the specialty mattress. Refer to Local Coverage Determination L33642.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS009
|
The order is dated greater than 30 days after the beneficiary was discharged from a hospital or nursing facility. Refer to Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS010
|
The medical record documentation indicates that all ulcers on the trunk or pelvis are healed.
Refer to Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS011
|
The medical record documentation shows ulcer healing has not continued, and does not demonstrate other aspects of the care plan are being modified to promote healing or the use of the group 2 support surface is reasonable and necessary for wound management. Refer to
Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS012
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program. Refer to Local Coverage Determination L33642 and
Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS013
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included use of an appropriate group 1 support surface. Refer to Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS014
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included use of an appropriate group 1 support surface within the past month. Refer to Local Coverage Determination L33642 and Policy
Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS015
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included regular assessment by a nurse, physician, or other licensed healthcare practitioner within the past month. Refer to Local
Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS016
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included appropriate turning and positioning within the past month. Refer to Local Coverage Determination L33642 and Policy Article
A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS017
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included appropriate wound care within the
past month. Refer to Local Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS018
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included appropriate management of moisture/incontinence within the past month. Refer to Local Coverage Determination L33642
and Policy Article A52490.
|
|
DMEPOS
|
Group 2 Pressure Reducing Support Surfaces (PRSS)
|
SS019
|
The medical record documentation does not demonstrate the beneficiary has been on a comprehensive ulcer treatment program which included nutritional assessment and intervention consistent with the overall plan of care within the past month. Refer to Local
Coverage Determination L33642 and Policy Article A52490.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXA
|
The file is corrupt and/or cannot be read
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXB
|
The submission was sent to the incorrect review contractor
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXC
|
A virus was found
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXD
|
Other
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXE
|
The system used to retrieve the Subscriber/Insured details using the given MBI is temporarily
unavailable.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXF
|
The documentation submitted is incomplete
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXG
|
This submission is an unsolicited response
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXH
|
The documentation submitted cannot be matched to a case/claim
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXI
|
This is a duplicate of a previously submitted transaction
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXJ
|
The date(s) of service on the cover sheet received is missing or invalid.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXK
|
The NPI on the cover sheet received is missing or invalid.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXL
|
The state where services were provided is missing or invalid on the cover sheet received.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXM
|
The Medicare ID on the cover sheet received is missing or invalid.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXN
|
The billed amount on the cover sheet received is missing or invalid.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXO
|
The contact phone number on the cover sheet received is missing or invalid.
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXP
|
The Beneficiary name on the cover sheet received is missing or invalid
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXQ
|
The Claim number on the cover sheet received is missing or invalid
|
|
DMEPOS
|
Administrative/Other
(For Transmission via esMD)
|
PMDXR
|
The ACN on the coversheet received is missing or invalid
|
