Most Frequent RTP Reason Codes - Palmetto GBA

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Reason Codes FISS Narrative 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. Explanation and Suggestion 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
Reason Codes FISS Narrative 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. Explanation and Suggestion 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.
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Most Frequent RTP Reason Codes - Palmetto GBA

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