Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Policy for Intensive Behavioral Therapy (Rev. 3232, 01-05-15)

by  Jared Staheli
July 7th, 2015

Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for obesity counseling sessions:

• Denying services submitted on a TOB other than 13X and 85X:

CARC 171 – Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC N428 - Not covered when performed in this place of service.

MSN 16.2 - This service cannot be paid when provided in this location/facility.

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).

NOTE: For modifier GZ, use CARC 50 and MSN 8.81.

• Denying services for obesity counseling sessions HCPCS code G0473 or G0447 with 1 of the ICD-9 codes (V85.30-V85.39 or V85.41-V85.45) when billed for a total of more than 22 sessions in the same 12-month period:

CARC 119 – Benefit maximum for this time period or occurrence has been reached.

RARC N362 – The number of days or units of service exceeds our acceptable maximum.

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 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).

NOTE: For modifier GZ, use CARC 50 and MSN 8.81.

• Denying claim lines for obesity counseling sessions HCPCS code G0473 or G0447 without 1 of the appropriate ICD-9 codes (V85.30-V85.39 or V85.41- V85.45):

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.

MSN 14.9 - Medicare cannot pay for this service for the diagnosis shown on the claim.

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).

NOTE: For modifier GZ, use CARC 50 and MSN 8.81.

• Denying claim lines without the appropriate POS code:

CARC 5 - The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC M77 - Missing/incomplete/invalid place of service.

MSN 21.25 - This service was denied because Medicare only covers this service in certain settings.

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).

NOTE: For modifier GZ, use CARC 50 and MSN 8.81.

• Denying claim lines that are not submitted from the appropriate provider specialties:

CARC 8 - The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC N95 - This provider type/provider specialty may not bill this service.

MSN 21.18 - This item or service is not covered when performed or ordered by this provider.

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).

NOTE: For modifier GZ, use CARC 50 and MSN 8.81.

References:

Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Policy for Intensive Behavioral Therapy (Rev. 3232, 01-05-15). (2015, July 7). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/claim-adjustment-reason-codes-carcs-remittance-advice-remark-codes-rarcs-group-codes-and-medicare-summary-notice-msn-messages-for-policy-for-intensive-behavioral-therapy-rev-3232-01-05-15-27085.html

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