Claim Change Reasons

50.2 - Claim Change Reasons (Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014) A. - Claim Change Reason Codes The provider submits one of the following claim change reason codes to its A/B MAC (A) with each debit-only or cancel-only adjustment request: Bill Type Reason Code Explanation XX7 D0 (zero) Change to service dates XX7 D1 Change in charges XX7 D2 Change in revenue codes/HCPCS XX7 D3 Second or subsequent interim PPS bill - inpatient only XX7 D4 Change in GROUPER input (diagnoses or procedures) - inpatient only XX8 D5 Cancel-only to correct a HICN or provider identification number XX8 D6 Cancel-only to repay a duplicate payment or OIG overpayment (includes cancellation of an outpatient bill containing services required to be included on the inpatient bill.) XX7 D7 Change to make Medicare the secondary payer XX7 D8 Change to make Medicare the primary payer XX7 D9 Any other change Bill Type Reason Code Explanation XX7 E0 (zero) Change in patient status The provider may not submit more than one claim change reason code per adjustment request. It must choose the single reason that best describes the adjustment it is requesting. It should use claim change reason code D1 only when the charges are the only change on the claim. Other claim change reasons frequently change charges, but the provider may not "add" reason code D1 when this occurs. The claim change reason code is entered as a condition code on the ASC X12 837 institutional claim format or on the hard copy Form CMS-1450 For reason codes D0-D4 and D7-D9, submit a debit-only adjustment request, bill type XX7. For reason codes D5 and D6, submit a cancel-only adjustment request, bill type XX8. B. - Edits on Claim Change Reason Codes The following edits are based on the claim change reason code. The A/B MAC (A) must apply them to each incoming adjustment request. • If the type of bill is equal to XX7 and the claim change reason code is not equal to D0-D4, D7-D9, or E0, the A/B MAC (A) rejects the request back to the provider with the following error message, "Claim change reason code must be present and equal to D0-D4, D7-D9, or E0 for a debit-only adjustment request." • If the type of bill is equal to XX8 and the claim change reason code is not equal to D5-D6, the A/B MAC (A) rejects the request back to the provider with the following error message, "Claim change reason code must be present and equal to D5-D6 for a cancel-only adjustment request." • If the type of bill is equal to XX7 or XX8 and the ICN/DCN of the claim being adjusted is not present, the A/B MAC (A) rejects the request back to the provider with the following message, "ICN/DCN of the claim being adjusted is required for an adjustment request." • If more than one claim change reason code is present on the provider's request, the A/B MAC (A) rejects the request back to the provider with the following message, "only one claim change reason code may apply to a single adjustment request from a provider. Choose the single claim change reason code that best describes the reason for the provider's request and resubmit." • If the provider submits an adjustment request as type of bill not equal to XX7 or XX8, the A/B MAC (A) rejects the request back to the provider with the message, "Provider submitted adjustment request must use type of bill equal to XX7 or XX8." • If the claim change reason code is equal to D0, the A/B MAC (A) compares the beginning and ending dates on the provider's request to those on the claim to be adjusted on its history. If these dates are the same, it rejects the request back to the provider with the message, "Dates of service must change for claim change reason code D0." • If the claim change reason code is equal to D1, the A/B MAC (A) compares the total and line item charges on the provider's request to those on the claim to be adjusted on its history. If these changes are the same, the A/B MAC (A) rejects the request back to the provider with the message, "Charges must be changed for claim change reason code D1." • If the claim change reason code is equal to D2, the A/B MAC (A) compares revenue codes/HCPCS on the provider's request to those on the claim to be adjusted on its history. If these codes are the same, it rejects the request back to the provider with the message, "Revenue codes/HCPCS must change for claim change reason code D2." • If the claim change reason code is equal to D3, the A/B MAC (A) compares the ending date on the provider's request to that on the claim to be adjusted on its history. If these dates are the same, it rejects the request back to the provider with the message, "Thru dates must change for the claim change reason code D3." • If the claim change reason code is equal to D4, the A/B MAC (A) compares diagnosis and procedure codes on the provider's request to those on the claim to be adjusted on its history. If these codes are the same and are in the same sequence, it rejects the request back to the provider with the message, "Diagnoses and/or procedures must change for claim change reason code D4." • If the claim change reason code is equal to D5 or D6, type of bill must be equal to XX8 on the provider's request. If type of bill is not equal to XX8, the A/B MAC (A) rejects the request back to the provider with the message, "Type of bill must be equal to XX8 for claim change reason codes D5 or D6." • If the claim change reason code is equal to D7, an MSP value code (12-16, 41-43, or 47) must be present, if a value code, 12-16, 41-43, or 47, is not present, the A/B MAC (A) rejects the request back to the provider with the message, "An MSP value code (12-16, 41-43, or 47) must be present for claim change reason code D7." • If the claim change reason code is equal to D7, and one or more of value codes 12-16, 41-43, and/or 47 is present but each value amount is equal to 0 (zero) or spaces, the A/B MAC (A) rejects the request back to the provider with the message, "invalid value amount for claim change reason code D7." • If the claim change reason code is equal to D8, and a value code 12-16, 41-43, or 47 is present, the A/B MAC (A) rejects the claim back to the provider with the message, "Invalid value code for claim change reason D8." • If the claim change reason code is equal to E0, the A/B MAC (A) compares patient status on the provider's request to that on the claim to be adjusted. If patient status is the same, the A/B MAC (A) rejects the request back to the provider with the message, "Patient status must change for claim change reason E0." If an adjustment the provider initiates results in a change to a higher weighted DRG, the A/B MAC (A) edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted. If it is, the A/B MAC (A) processes the claim for payment. If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the A/B MAC (A) processes the claim for payment and forwards it to CWF. The A/B MAC (A) must suspend for investigation all adjustment requests with claim change reason codes D4, D8, and D9. Providers that consistently use D9 will be investigated and, if a pattern of abuse is evident, may be reported to the OIG. C. - Additional edits The A/B MAC (A) must perform the following additional edits and investigate adjustment requests the provider submits: • A full denial once the bill is paid, except to accomplish retraction of a duplicate payment; • A change in DRG based on a change in age or sex; • A change in deductible; • An adjustment request that changes a previously submitted QIO adjustment request; • An adjustment of a bill due to a change in utilization or spell data on another bill; • A reopening to change a no-payment bill to a payment bill; • A reopening to pay a previously denied line item; • An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or • An adjustment request with a claim change reason code equal to E0, and the claim is for a PPS provider. The A/B MAC (A) must investigate if the change is from patient status 02, transferred to another acute care facility.