Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs),

11.3.6 – Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs) and Group Codes (Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02- 14-22 MACs) Contractors shall deny claims for PRP services when provided on other than TOBs 12X, 13X, 22X, 23X, 71X, 75X, 77X, and 85X using: MSN 21.25 - “This service was denied because Medicare only covers this service in certain settings.” Spanish Version - “El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.” CARC 58 - “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present. RARC N428 - “Service/procedure not covered when performed in this place of service.” Group Code - CO (Contractual Obligation) Contractors shall reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service when the --KX modifier is NOT included on the claim using 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 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. Medicare Summary Notice (MSN) 20.5 – These services cannot be paid because your benefits are exhausted at this time. Spanish Version: “Estos servicios no pueden ser pagados porque sus beneficios se han agotado.” Group Code – CO (Contractual Obligation) Contractors shall deny/reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that don’t contain the appropriate diagnosis codes as noted above and use the following messages: Claim Adjustment Reason Code (CARC) 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer. Remittance Advice Remark Code (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. Medicare Summary Notice (MSN) 15.19 - “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare-coverage-database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor." Spanish Version -Usamos una Determinación de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN para el código "CPT/HCPCS") y envíela con la información de su médico. MSN 15.20 - “The following polices were used when we made this decision: NCD 270.3.” Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 270.3.” NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN. Group Code – Contractual Obligation (CO).