Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)

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 alcohol misuse screening and alcohol misuse behavioral counseling sessions:

• For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 and alcohol misuse counseling HCPCS code G0443 with another encounter/visit with the same line item date of service, use group code CO and reason code:

° Claim Adjustment Reason Code (CARC) 97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present

• Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a TOB other than 13X, 71X, 77X, and 85X:

o Claim Adjustment Reason 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

o Remittance Advice Remark Code (RARC) M77 – Missing/incomplete/invalid place of service

o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.

o 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.

• Denying claims that contains more than one alcohol misuse behavioral counseling session G0443 on the same date of service:

o Medicare Summary Notice (MSN) 15.6 – The information provided does not support the need for this many services or items within this period of time.

o Claim Adjustment Reason Code (CARC) 151 – Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

o Remittance Advice Remark Code (RARC) M86 – Service denied because payment already made for same/similar procedure within set time frame.

o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.

o 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.

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

° Medicare Summary Notice (MSN) 21.18 – This item or service is not covered when performed or ordered by this provider.

° Claim Adjustment Reason Code (CARC) 185 - The rendering provider is not eligible to perform the service billed. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

° Remittance Advice Remark Code (RARC) N95 - This provider type/provider specialty may not bill this service.

° Group Code PR (Patient Responsibility) assigning financial liability 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.

• Denying claims without the appropriate POS code:

° Medicare Summary Notice (MSN) 21.25 – This service was denied because Medicare only covers this service in certain settings.

° Claim Adjustment Reason Code (CARC) 58 – Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.

° Remittance Advice Remark Code (RARC) N428 – Not covered when performed in this place of service.

° Group Code PR (Patient Responsibility) assigning financial liability 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.

• Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a 12-month period, and denying alcohol misuse counseling sessions HCPCS code G0443 more than four times in the same 12-month period:

° Medicare Summary Notice (MSN) 20.5 – These services cannot be paid because your benefits are exhausted at this time.

° Claim Adjustment Reason Code (CARC) 119 – Benefit maximum for this time period or occurrence has been reached.

° Remittance Advice Remark Code (RARC) N362 – The number of Days or Units of service exceeds our acceptable maximum.

° Group Code PR (Patient Responsibility) assigning financial liability 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.

Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11). (2015, July 7). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/claim-adjustment-reason-codes-remittance-advice-remark-codes-group-codes-and-medicare-summary-notice-messages-for-alcohol-screening-and-behavioral-counseling-interventions-rev-2433-10-14-11-27066.html

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