Latest Review Reason Codes

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