Most Frequent RTP Reason Codes - Palmetto GBA

Most Frequent RTP Reason Codes 

The following provides an explanation and suggestions for correction of the top fifteen reason 

code errors by North Carolina Skilled Nursing Facility providers, which have created the greatest 

number of returns to provider (RTPs) during the month of November, 2009. 

Reason 

Codes 

FISS Narrative 

Explanation and Suggestion 

38119 BILLS FOR A CONTINUOUS STAY OR 

ADMISSION MUST BE SUBMITTED IN THE 

SAME SEQUENCE IN WHICH THE 

SERVICES ARE FURNISHED. IF YOU HAVE 

NOT ALREADY DONE SO, PLEASE SUBMIT 

THE PRIOR BILL, THEN RESUBMIT THIS 

BILL AFTER YOU RECEIVE THE 

REMITTANCE ADVICE FOR THE PRIOR 

BILL. 

12206 WHEN THE FROM AND THROUGH DATES 

ARE NOT THE SAME ON INPATIENT OR 

SNF BILL TYPES 11X, 18X, 21X, 28X, 41X, 

OR 51X THE NUMBER OF DAYS 

REPRESENTED MUST EQUAL THE SUM OF 

THE COVERED DAYS PLUS THE NON 

COVERED DAYS,UNLESS THE PATIENT 

STATUS IS 30 AND 1 ADDITIONAL DAYS IS 

USED IN THE CALCULATION. 

IF THE DATES ARE THE SAME, THE BILL 

MUST SHOW ONLY 1 DAY. THIS REASON 

CODE WILL BE BYPASSED IF THE TYPE OF 

BILL IS XX5 AND THE UB82-92 INDICATOR 

IS A '9' AND THERE ARE NO COVERED 

DAYS. 

12302 THIS REASON CODE ONLY APPLIES TO 

SNF AND INPATIENT BILLS ONLY, TOB 11X, 

41X, 18X, 21X, 22X, 23X, 24X AND 51X. 

COVERED DAYS: THE SUM OF THE 

UTILIZATION DAYS CALCULATED PLUS 

THE NUMBER OF THE NON-UTILIZATION 

DAYS CALCULATED MUST EQUAL THE 

NUMBER OF DAYS BETWEEN THE FROM 

AND THROUGH DATES IN THE STATEMENT 

COVERS PERIOD UNLESS: 

1. PATIENT STATUS = 30 (ADD ONE DAY TO 

THE CALCULATION). 

2. TRANSFER - THE FROM AND THROUGH 

DATE ARE THE SAME, PATIENT STATUS 02, 

03, 05, 50, 51, 61, 62, 63, 71 OR 72 WITH A 

CONDITION CODE 40. 

3. THE FROM AND THROUGH DAYS ARE 

This reason code occurs when SNF inpatient 

claims are “out of sequence.” The claim 

receiving this reason code does not directly 

follow the thru date of the previous paid claim 

for this Medicare beneficiary from this provider. 

In many instances, the claim that breaks the 

sequential chain may be in process (check the 

Claims Inquiry screen #12 for a claim in Status 

‘S’ or ‘T’). If so, the current claim cannot 

continue processing until the “in sequence” 

claim is paid (you receive the claim on a 

remittance advice). If the “in sequence” claim is 

not already in FISS, it must be submitted and 

paid before the current claim can process. 

This reason code indicates the number of days 

represented by the from and through dates on 

the claim have not been counted correctly. 

Frequently this count is incorrect by one day 

based upon whether the patient status code is 

a discharge status or still patient (code 30). If 

the patient status code is a discharge status, 

the through date is not included in the count. If 

the patient status code is still patient (30), the 

through date is added to the count of total days 

This reason code is also an indication that the 

total number of days represented by the from 

and through dates has not been calculated 

correctly. This reason code may frequently be 

received in conjunction with reason code 12206 

(above). Be certain to take note of the factors 

indicated in the reason code narrative to assure 

that the days are being calculated as expected 

by FISS and the Medicare program.




THE SAME BUT NO CONDITION CODE 40 

PRESENT. 

38117 THE TOB IS EQUAL TO AN SNF, OR THE 

CLAIM IS FOR A NON-PPS INPATIENT, OR 

AN IPF PPS. THE ADMISSION DATE IS ON 

OR AFTER 040195, AND THE STATEMENT 

COVERS FROM DATE IS GREATER THAN 

THE ADMISSION DATE. THERE IS A PRIOR 

CLAIM PENDING, AND THE PRIOR CLAIM'S 

THRU DATE IS 1 DAY LESS THAN THIS 

CLAIM'S FROM DATE, AND THE REASON 

CODE AUTHORIZATION FIELD (CLAIM 

PAGE 9) DOES NOT CONTAIN THIS 

REASON CODE. 


The admission date in FL 17 is prior to the 

statement from date of this claim. **OR** The 

prior claim in the series shows a thru date that 

is one day less than 

31486 THE CLAIM IS AN SNF CLAIM WITH A 

STATEMENT COVERS FROM DATE OF 

7/1/98 OR GREATER AND THE SUM OF ALL 

REVENUE CODES 0022 DOES NOT EQUAL 

THE CLAIM COVERED DAYS COUNT. 

15202 FOR 11X, 18X, OR 21X BILLS, THE 

COVERED DAYS (FLD 7) MUST 

EQUAL THE ACCOMMODATION UNITS (FLD 

46) FOR REVENUE CODES 

10X - 21X. PLEASE MAKE CORRECTIONS 

AND RESUBMIT/REKEY. 

HARDCOPY SUBMITTORS RESUBMIT RTP 

REPORT WITH CORRECTIONS. 

W7K01 STANDARD NARRATIVE: THE OPPS 

VERSION OF OCE HAS DETECTED 

AN ERROR IN THE ADMITTING DIAGNOSIS. 

This reason code can indicate that the units 

field billed on the revenue line for the HIPPS 

code (revenue code 0022) does not match the 

number of covered days shown on page 1 of 

the claim in FISS. However, for most of the 

claims receiving this reason code the problem 

is that a non-covered claim is being billed, but 

the provider is showing covered units (field 

name = COV UNIT) for revenue code 0022. If 

the claim is a totally non-covered claim, please 

remove all covered units. 

Provider should be certain that the units 

(including covered units on page 2 of claim in 

FISS) billed with accommodation revenue 

codes (10X-21X) equal the number of covered 

days (page 1) billed on the claim. If all of the 

days and the units appear to be correct but this 

reason code is still returned, contact the 

Provider Contact Center (PCC) for assistance. 

This reason code indicates that the admitting 

diagnosis code (the code in the ADMITTING 

DIAGNOSIS field on claim page 03) for the 

date of service billed does not match a valid 

code in the OPPS version of the Outpatient 

Code Editor (OCE). Check this code against 

the FISS ICD-9-CM code file (Menu Option 

#15) and correct it accordingly 

11801 IF THE TYPE OF BILL IS EQUAL TO 11X, OR 

41X IF THE ADMISSION TYPE IS EQUAL TO 

1, 2, 3, OR 9, THEN THE ADMISSION 

SOURCE MUST BE EQUAL TO 1 THRU 9; 

OR 

IF THE ADMISSION TYPE IS EQUAL TO 4, 

Generally the receipt of this reason code 

means that the admission source code was not 

included on this claim. Please add the 

appropriate admission source code to allow the 

claim to continue processing. If the admission 

source code is present on the claim, please




THEN THE ADMISSION SOURCE MUST BE 

EQUAL TO 1, 2, 3, OR 4; 

OR 

IF THE TYPE OF BILL IS EQUAL TO 13X, 

14X, 83X, OR 85X, AND THE DATE OF 

SERVICE IS GREATER THAN 02/28/91, 

THEN THE ADMISSION SOURCE MUST BE 

EQUAL TO 1 THRU 8; 

OR 

IF THE TYPE OF BILL IS EQUAL TO 18X, 

21X, 28X, OR 51X, THEN THE ADMISSION 

SOURCE MUST BE A SPACE OR EQUAL TO 

AN 'A' OR 1 THRU 9. 

OR 

IF THE TYPE OF BILL IS EQUAL TO 3X2 OR 

3X9, AND THE DATE OF SERVICE IS 

10/01/00 OR GREATER THEN THE 

ADMISSION SOURCE MUST BE 1 THRU 9, 

A, B, OR C. 

OR 

IF THE DATE OF SERVICE IS EQUAL TO OR 

GREATER THAN 1/1/08 THE ADMISSION 

SOURCE CODE OF 'A' OR '3' IS NO LONGER 

VALID. 

32404 ACCORDING TO THE REVENUE CODE FILE 

A HCPC IS REQUIRED. HOWEVER, THE 

HCPC THAT WAS ENTERED ON THE CLAIM 

WAS NOT FOUND ON THE HCPC FILE 

CORRECTIONS WITH REPORT. 

32200 WHEN DIAGNOSIS CODE 'V048' OR 'V0382' 

IS PRESENT ON A CLAIM, A CONDITION 

CODE 'A6' IS REQUIRED FOR THE 

FOLLOWING BILL TYPES: 

12X, 13X, 14X, 22X, 23X, 24X, 34X, 72X, 74X, 

75X, 85X. 


review the conditions listed in the reason code 

narrative to determine if the code is correct 

according to the other factors/data elements 

included on the claim, and change the code 

accordingly. 

Please refer to the most current CPT-4 HCPCS 

coding book to verify that the HCPCS being 

billed is valid for the dates of service on the 

claim. Make any necessary corrections and 

resubmit. Hardcopy submittors resubmit. 

Diagnosis codes ‘V048’ and ‘V0382’ are used 

to indicate that the patient involved is in need of 

a vaccination (influenza and pneumonia, 

respectively). Medicare billing guidelines 

require that the special program indicator, 

condition code ‘A6’, be included on all claims 

billing for these services. Therefore, this reason 

code is generated whenever these diagnosis 

codes are present and condition code ‘A6’ is 

not. Add condition code ‘A6’ and the claim 

should proceed to payment, or the diagnosis 

codes should be removed if the vaccinations 

were not provided. 

32415 CONDITION CODE A6 IS REQUIRED WHEN 

ONE OR MORE OF THE FOLLOWING 

HCPCS ARE PRESENT ON THE CLAIM: 

HCPC Q0124 WITH FROM DATE LESS THAN 

010195 OR 90657, 90658, 90659, 90669, 

90724, 90732, G0008 OR G0009. 

This reason code occurs because the provider 

has not included condition code ‘A6’ (special 

program indicator for vaccine billing – 

deductible and coinsurance do not apply) on 

the claim but there is a pneumonia vaccine or 

influenza vaccine being billed. Either the 

‘A6’should be added, or the listed HCPCS/CPT 

codes should be removed from the claim.





153#1 TOTAL CHARGES: THE TOTAL CHARGES 

ON REVENUE CODE 001 MUST BE EQUAL 

TO THE SUM OF ALL THE CHARGES 

ABOVE IT. 

30949 TYPE OF BILL EQUALS XX7 OR XX8 BUT 

NO CONDITION CODE IS PRESENT ON THE 

BILL. PLEASE INCLUDE THE APPROPRIATE 

CONDITION CODE OF 

D0 - CHANGES TO SERVICE DATES 

D1 - CHANGES IN CHARGES 

D2 - CHANGES IN REVENUE CODE/HCPC 

D3 - SECOND OR SUBSEQUENT INTERIM 

PPS BILL 

D4 - CHANGE IN GROUPER INPUT (DRG) 

D5 - CANCEL ONLY TO CORRECT A HIC OR 

PROVIDER NUMBER 

D6 - CANCEL ONLY - DUPLICATE 

PAYMENT, OUTPATIENT TO INPATIENT 

OVERLAP, OIG OVERPAYMENT 

D7 - CHANGE TO MAKE MEDICARE 

SECONDARY PAYER 

D8 - CHANGE TO MAKE MEDICARE 

PRIMARY PAYER 

D9 - ANY OTHER CHANGES. 

PLEASE MAKE CORRECTIONS AND 

RESUBMIT/REKEY. 

13314 FOR OCCURRENCE SPAN CODE 

70(QUALIFYING STAY DATE) THE "FROM" 

DATE IS GREATER THAN THE "THROUGH" 

DATE. *VERIFY THE QUALIFYING STAY 

THRU DATE (REPORTED WITH 

OCCURRENCE CODE 70) IS GREATER 

THAN THE ADMISSION DATE OF THE 

CLAIM. 

OR 

THIS IS A SNF, AND THE OCCURRENCE 

SPAN CODE 80 (PRIOR SAME-SNF STAY) 

FROM DATE IS GREATER THAN THE CLAIM 

ADMISSION FROM DATE. 

31094 TOTAL COVERED CHARGES CANNOT BE 

GREATER THAN ZERO IF THE THIRD 

POSITION OF THE TYPE OF BILL (TOB) 

EQUALS ZERO. PLEASE VERIFY THE TYPE 

This reason code indicates that the Total 

Charges revenue line (0001) contains a charge 

that is not the sum total of the line items on this 

claim. This may be an indication that some line 

item changes were made but the Total Charge 

line was not “deleted” and re-entered with the 

corrected total charge amount. If the Total 

Charge line item is not “corrected” in the same 

manner as all other line items, this reason code 

is likely to occur. 

In this instance, the provider is submitting an 

adjustment (type of bill = xx7) or a paid claim 

cancellation (xx8), but they have failed to 

include the claim change condition code (FL 

24-30) that explains the adjustment or 

cancellation. Please add one of the condition 

codes listed in the reason code narrative to 

your claim. 

On most of the claims receiving this reason 

code the Admission Date billed on the claim is 

BEFORE the qualifying stay date (occurrence 

code 70) which is incorrect. It appears that an 

”old” (prior) admit date is being used rather 

than the admit date that relates to the from and 

through dates on the current claim. Please 

review the admit date, the qualifying stay date 

and the from and through date on the claim to 

assure that the appropriate, current dates are 

being used and that they are in the proper 

sequence. 

This reason code is received because the claim 

is billed with a zero (0) in the third position of 

the type of bill (TOB) indicating a no pay and/or 

non-covered claim, but the charges on the




OF BILL AND/OR THE TOTAL COVERED 

CHARGES REPORTED. PLEASE CORRECT 

AND RESUBMIT/REKEY. HARDCOPY 

SUBMITTORS RESUBMIT RTP REPORT 

WITH CORRECTIONS. 


claim are listed as covered charges. In some 

cases the type of bill may be reported 

incorrectly. If this is the case please update the 

type of bill (TOB). If this is in fact a no pay 

and/or non-covered claim, the charges must be 

moved to the non-covered column. 

If you encounter some other reason code that you are unable to decipher, please submit it to us 

using the “I Have a Question” form included in the Medicare Advisory.

Most Frequent RTP Reason Codes - Palmetto GBA

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