Applicable ASC Messages for Certain Payment Indicators

60.3 – Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009 (Rev. 11793; Issued:01-19-23; Effective: 02-21-23; Implementation: 02-21-23) Contractors shall deny services for HCPCS codes with payment indicators C5 (Inpatient surgical procedure under the OPPS; no payment made.), M6 (No payment made; paid under another fee schedule), U5 (Surgical unlisted service excluded from ASC payment. No payment made.), or X5 (Unsafe surgical procedure in ASC. No payment made). The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four. Group Code: CO CARC: 5 RARC: N/A MSN: 16.32 Contractors shall deny services for CPT codes with payment indicators E5 (Surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made), or Y5 (Non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made). The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three. Group Code: PR CARC: 96 RARC: N425 MSN: 16.10 NOTE: Contractors shall assign beneficiary liability for facility charges HCPCS codes billed with ASC payment indicators C5, E5, U5 and X5. Contractors return as unprocessable services for HCPCS codes with payment indicator D5 (Deleted/discontinued code; no payment made). The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two. Group Code: CO CARC: 181 RARC: N56 MSN: N/A Contractors shall deny services for HCPCS with payment indicators L1 (Influenza vaccine; pneumococcal vaccine, Covid-19 Vaccine, monoclonal antibody therapy product. Packaged item/service; no separate payment made), NI (Packaged service/item; no separate payment made) or S1 (Service not surgical in nature; and not a radiology service payable under the OPPS, drug/biological, or brachytherapy source. Packaged item/service; no separate payment made). The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four. Group Code: CO CARC: 97 RARC: N390 MSN: 16.32 Contractors shall return as unprocessable services for HCPCS with payment indicators B5 (Alternative code may be available; no payment made). The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two. Group Code: CO CARC: 16 RARC: M51 MSN: N/A