Remittance Advice Codes

30.9 - Remittance Advice Codes (Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) Pap Smear Screening: If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ANSI X12N 835: • Claim adjustment reason code 119 - “Benefit maximum for this time period has been reached” at the line level, and • Remark code M83 - “Service is not covered unless the patient is classified as at high risk” at the line item level. HPV Screening: Effective for claims with dates of service on and after July 9, 2015: A. If denying line-items on claims containing HCPCS G0476, HPV screening, when reported more than once in a 5-year period [at least 4 years and 11 months (59 months total) must elapse from the date of the last screening], use the following messages: CARC 119: “Benefit maximum for this time period or occurrence has been reached.” RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.” Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file). Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). B. If denying line-items on claims containing HCPCS G0476, HPV screening, when the beneficiary is not between the ages of 30-65, use the following messages: CARC 6: “The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.” RARC N129: “Not eligible due to the patient’s age.” Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file). Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). C. If denying line items on claims containing HCPCS G0476, HPV screening, when the claim does not contain the appropriate ICD-10 diagnosis codes listed below: ICD-10: Z11.51 and Z01.411, or, Z01.419 Use the following messages: CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.” Group Code CO assigning financial liability to the provider