Medicare Part B Newsline April 2012 - Cahaba GBA

April 2012 

This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. 

Bulletins are available at no cost from our Web site at https://www.cahabagba.com. 

News From Cahaba GBA 

Disclaimer………………….……………………....….… 2 

Please Route…………………………………………….. 3 

General Medicare Questions for Medicare Recipients….. 3 

Holiday Closure Schedule……………………………..... 4 

Provider Contact Center (PCC) Training Schedule……... 5 

Provider Contact Center (PCC) Telephone Numbers…... 5 

Using the Interactive Voice Response (IVR) System for 

Claim Status and Eligibility Requests......……….........… 6 

Medicare Health Insurance Claim (HIC) Number……… 7 

Cahaba’s E-Mail Notification Service………...………… 8 

Cahaba University………………………………………. 9 

AL-Top Five Reasons for Claim Rejections- Feb 2012... 10 

GA-Top Five Reasons for Claim Rejections- Feb 2012... 11 

MS-Top Five Reasons for Claim Rejections- Feb 2012... 12 

TN-Top Five Reasons for Claim Rejections- Feb 2012.... 13 

AL-Top 277CA Claim Rejections- Feb 2012……..……. 14 

GA-Top 277CA Claim Rejections- Feb 2012…………... 17 

MS-Top 277CA Claim Rejections- Feb 2012…………... 20 

TN-Top 277CA Claim Rejections- Feb 2012..…………. 22 

Medicare Coverage Database (MCD) Article: 

Educational Article- Chiropractor Services- Retired…… 25 

Local Coverage Determinations- Comment Period for 

Draft LCDs…………………………………………….... 26 

Claim Specific CERT Errors- February 2012…………... 27 

Medicare B Newsline Quality Survey……….….............. 41 

News From CMS 

News Flash Messages From CMS………….……….…. 28 

Intensive Behavioral Therapy (IBT) for Obesity- 

Revised………………………………………………… 31 

Processing Form CMS-855O Submissions Instructions.. 37 

Revised Remittance Advice Remark Code (RARC) 

N103 when Denying Services Furnished to Federally 

Incarcerated Beneficiaries-Revised……………………. 39 

General Medicare Questions for Medicare 

Recipients 

Do some of your patients have questions regarding their 

Medicare benefits and you are not sure how to answer? 

Medicare recipients should call 1-800-MEDICARE (1-800- 

633-4227) for all questions related to Medicare services. 

Questions regarding specific claims will be automatically 

routed to the appropriate Medicare contractor’s call center for 

response. 

Key For Icons 

All Providers 

Claims 

End Stage Renal Disease (ESRD) 

Radiology 

Skilled Nursing Facility (SNF) 

The Medicare B Newsline provides information for those providers who submit claims to Cahaba Government Benefit 

Administrators ® , LLC. The CPT codes, descriptors and other data only are copyright © 2011 American Medical Association. All 

rights reserved. Applicable FARS/DFARS apply.

Disclaimer 

This educational material was prepared as a tool to assist Medicare providers and other interested parties and is not intended to 

grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information 

within this module, the ultimate responsibility for the correct submission of claims lies with the provider of services. Cahaba 

GBA, LLC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare 

information is error-free and will bear no responsibility or liability for the results or consequences of the use of these materials. 

This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The 

official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. 

We encourage users to review the specific statues, regulations and other interpretive materials for a full and accurate statement 

of their contents. Although this material is not copyrighted, CMS prohibits reproduction for profit making purposes. 

American Medical Association Notice and Disclaimer 

CPT codes, descriptors and other data only are Copyright 2011 American Medical Association. All rights reserved. 

ICD-9 Notice 

The ICD-9-CM codes and descriptors used in this material are copyright 2011 under uniform copyright convention. All rights 

reserved. 

Medicare B Newsline April 2012 2

News From Cahaba GBA for All Part B Providers 

Please Route 

Remember that this newsletter, and all other Medicare publications, serves as your official notice of 

Medicare coverage and billing information. If you have any questions about the information included in this 

newsletter, please call your Provider Contact Center. 

This bulletin shall be shared with all health care practitioners and managerial members of your provider 

staff. Bulletins are available at no cost from our website 

https://www.cahabagba.com/part_b/education_and_outreach/newsletters/index.htm. 

Routing List 

Provider/Supplier 

Administrator 

Office/Clinic Manager 

Medical Personnel 

Billing/Insurance Staff 

Other Additional Staff 

General Medicare Questions for Medicare Recipients 

Do some of your patients have questions regarding their Medicare benefits and you are not sure how to 

answer? Medicare recipients should call 1-800-MEDICARE (1-800-633-4227) for all questions related to 

Medicare services. Questions regarding specific claims will be automatically routed to the appropriate 

Medicare contractor’s call center for response. Please do not ask your patients to contact Medicare on 

a claim that you accepted assignment on. 


Holiday Closure Schedule-2012 

Cahaba GBA’s Medicare offices in Birmingham, AL; Douglasville, GA, Savannah, GA; and Chattanooga, 

TN are closed on the following days listed below in 2012. In addition, all Medicare Provider Contact 

Centers (PCC) close on federal holidays for continuing education training; therefore, customer service 

representatives will not be available on those days to receive your calls. 

Holiday / Date 

New Year’s Day Observed 

January 2, 2012 

Monday 

Martin Luther King Birthday 

January 16, 2012 

Monday 

President’s Day 

February 20, 2012 

Monday 

Good Friday 

April 6, 2012 

Friday 

Memorial Day 

May 28, 2012 

Monday 

Independence Day 

July 4, 2012 

Wednesday 

Labor Day 

September 3, 2012 

Monday 

Columbus Day 

October 8, 2012 

Monday 

Veterans Day Observed 

November 12, 2012 

Monday 

Thanksgiving 

November 22-23, 2012 

Thursday/Friday 

Christmas 

December 24-25, 2012 

Monday/Tuesday 

New Year’s Day 

January 1, 2013 

Tuesday 

Closure Schedule 

All Offices Closed 


PCC Closed for Training 











Provider Contact Center– Training Schedule 

Medicare is a continuously changing program, and it is important that we provide correct and accurate 

answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid 

Services (CMS) allows the Provider Contact Centers the opportunity to offer training to our Customer 

Service Representatives (CSRs). Listed below are the dates and times the Provider Contact Center will be 

closed for training. 

PCC Training Dates 

Friday, April 13, 2012 



Time 

9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 

9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 

9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 

Provider Contact Center Telephone Numbers 

Alabama B, Georgia B, and Tennessee B: 877 567-7271 

Mississippi B: 866 419-9454 

Our Interactive Voice Response (IVR) system is designed to assist providers in obtaining answers to 

numerous issues through self-service options. Options on our IVR include information regarding patient 

eligibility, checks, claims, deductible and other general information. Please note that our Customer Service 

Representatives (CSRs) are available to answer questions that cannot be answered by the IVR. CSRs are 

physically located in Birmingham, Alabama and Savannah, Georgia. When your call is received, it is routed 

to the next available representative. CSRs are available Monday through Friday 8:00 a.m. until 4:00 p.m. in 

your time zone. 


Using the Interactive Voice Response (IVR) System for Claim Status and 

Eligibility Requests 

Cahaba Government Benefit Administrators®, LLC is experiencing a high volume of providers who are 

opting out of the Interactive Voice Response (IVR) system to speak to a Customer Service Representative 

(CSR) for information that can be accessed through the IVR. 

The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Chapter 6 Section 

50.1 states: 

“Providers shall be required to use IVRs to access claim status and beneficiary eligibility 

information. CSRs shall refer providers back to the IVR if they have questions about claims status 

or eligibility that can be handled by the IVR. CSRs may provide claims status and/or eligibility 

information if it is clear that the provider cannot access the information through the IVR because the 

IVR is not functioning.” 

If you are requesting whether Cahaba has received a claim or if a claim has finalized, this is 

considered a claim status request. 

In addition, according to IOM Chapter 6 Section 80.3.4, “If a CSR or written inquiry correspondent receives 

an inquiry about information that can be found on a Remittance Advice (RA), the CSR/correspondent 

should take the opportunity to educate the inquirer on how to read the RA, in an effort to encourage the use 

of self-service. The CSR/correspondent should advise the inquirer that the RA is needed in order to answer 

any questions for which answers are available on the RA. Providers should also be advised that any billing 

staff or representatives that make inquiries on his/her behalf will need a copy of the RA.” 

Cahaba CSRs have visibility as to the path the provider takes in the IVR and/or whether they opt out to 

speak with a representative up front. The CSR will instruct the provider to call back and utilize the IVR if 

they did not attempt to use this self service option as required by CMS. 

Provider Contact Center (PCC) 


Medicare Health Insurance Claim (HIC) Number 

A Medicare card is issued to every person who is entitled to Medicare benefits and may be identified by its red, white 

and blue coloring. This card identifies the Medicare beneficiary and includes the following information: 

Name (exactly as it appears on the Social Security records); 

Medicare Health Insurance Claim (HIC) number; 

Beginning date of Medicare entitlement for hospital and/or medical insurance; 

Sex and Beneficiary's signature. 

Three of the top five reasons for claim rejection in any given month are for: 

The last name submitted for the beneficiary does not match the last name we have on record for the HIC 

number on the claim. The beneficiary's last name must include apostrophes, spaces, hyphens, etc., if they 

appear in the beneficiary's last name on his or her Medicare card. 

The first name submitted for the beneficiary does not match the first name we have on record for the HIC 

number on the claim. The beneficiary's first name must appear as it does on the beneficiary's Medicare 

card. This includes spaces, hyphens, apostrophes, etc. 

The HIC number not matching the name we have on record. The Medicare Claim Number must appear on 

the claim exactly as it does on the beneficiary’s card, without the dashes and with no spaces. 

It is extremely important that you submit the patient’s complete name and HIC number to Medicare or any other 

health care provider you use (i.e. clinical laboratories, radiology imaging groups, or outpatient therapy providers, 

etc.). This will ensure that those providers have the correct patient information to file their claims as well. 


Cahaba’s E-mail Notification Service Subscription Process 

Cahaba GBA recently implemented changes that simplify the process in which providers subscribe to our e- 

mail notification service (Listserv). New members simply provide their name, city, state, zip code, e-mail 

address, and an optional password. In addition, they can select from two different lists to subscribe to: 

• J10 Part A News 

• J10 Part B News* 

Once you are a member, you can edit your profile to: 

• unsubscribe from all lists 

• subscribe to additional lists 

• update your e-mail address 

• change your name or address information 

• change what Cahaba lists you are subscribed to. 

Already a Member? 

If you enrolled to Cahaba’s Listserv prior to November 1, 2009, you will continue to receive messages. 

However, depending on the selections you made on the subscription form when you originally enrolled, you 

may receive messages from more than one Cahaba list. To change the list you are subscribed to, access the 

“Edit Your E-mail Notification Service Member Profile” Web page to review and edit your profile. 

In order to ensure that you receive your subscription emails and announcements from Cahaba GBA, please 

add us to your contact lists, adjust your spam settings, or follow the instructions from your email provider 

on how to prevent our emails from being marked “Spam” or “Junk Mail”. 

*Mississippi Medicare Part B providers will choose J10 Part B News for their selection to receive Medicare 

Part B information. 


Cahaba University 

Cahaba University is an educational program designed to provide a broad variety of Medicare related 

training to meet the needs of Medicare health care providers and suppliers. It is powered by Centra, a 

learning management system that will allow registered users to manage their own learning. Cahaba 

University allows for a blended e-learning environment. Blended means that users are allowed to register for 

Webinars, teleconferences, as well as assign self-paced learning tracks. It also provides centralized 

management and access to content created by the Provider Outreach and Education department for the 

provider community. 

Our staff of well-trained professionals wants every provider to be pleased with their learning experience. 

We know you’re just as concerned about your claims being processed for your facility as you are about the 

quality of care administered to your Medicare patients. That is why we always try to provide additional 

education and outreach activities to help improve this process. 

All providers are encouraged to create a user profile. Click the “Create a new account” link, and then select 

either a Part A or Part B account. You must create a username and password to login. Make sure all the 

appropriate fields are completed. Once the account is created, log in using your new user name and 

password. Remember, your username and password is case-sensitive! 


Alabama Medicare Part B 

Top Five Reasons for EDI Claim Rejections for February 2012 

Audit trails show which of your claims were accepted by the Cahaba GBA Part A processing system, along 

with claims that were rejected and the reason for the rejection. Referring to this report will allow you to 

correct and resubmit claims quickly, resulting in a dramatically reduced turnaround time. You will also 

become aware of any major problems with your claims so they can be corrected before they create an 

interruption in your cash flow. Audit trail reports are available the next business day for files that are 

received before 3:30 p.m. Central Time. If you are not receiving your audit trails contact your software 

vendor, billing service, or clearing house. 

See Audit Trail Explanations for a more complete list of edits, along with descriptions of loops that might 

be referenced in an edit. 

In order to increase the number of claims that successfully pass through audit trails and into processing 

Cahaba GBA Part A EDI Services is providing you with the top five reasons for claim rejections. For the 

month of February 2012, these are: 

Claim Description 

Rejection 

382 NPI REQUIRED IN LOOP : XXXXXX WHEN 

PROVIDER IDENTI 

Provider information was submitted in the indicated loop but 

there was no XX qualifier in the NM108 for that provider. 

434 PROC CODE REQUIRES REFERRING NPI 

Procedure code billed was for a diagnostic procedure such as 

an x-ray or lab work which requires the NPI of the ordering 

physician, or a consultation, which requires the NPI of the 

referring physician, and this was not submitted on the claim. 

421 DIAG CODE (XXXXX) INVALID FOR DATE SVC 

The date of service was outside of the effective date range of 

the diagnosis code used. The invalid diagnosis code will 

appear inside the parenthesis. 

377 PAID & ADJUSTMENT AMOUNTS DO NOT EQUAL 

CLAIM CHARG 

The claim was submitted as Medicare Secondary Payer but the 

primary paid amount plus the primary adjustment amounts do 

not equal the total claim charge. 

888 INSTREAM REJECTION 

There was a problem involving HIPAA required loops, 

segments, or values. The specific loop will be identified, for 

example, 'ELEMENT N401 (D.E. 19) AT COL. 4 IS 

MISSING, THOUGH MARKED "MUST BE USED" 

(LOOP:2010BA POS:3140)'. The number after 'POS' 

indicates the position in the file where the error occurred 

Number of 

Claims 

1,139 

506 

497 

330 

246 


Georgia Medicare Part B 















Rejection 




example, 'ELEMENT N401 (D.E. 19) AT COL. 4 IS MISSING, 

THOUGH MARKED "MUST BE USED" (LOOP:2010BA 

POS:3140)'. The number after 'POS' indicates the position in the 

file where the error occurred 


The date of service was outside of the effective date range of the 

diagnosis code used. The invalid diagnosis code will appear 

inside the parenthesis. 

207 INVALID HIC NUMBER SUFFIX 

The suffix in the Health Insurance Claim (HIC) number 

submitted for the beneficiary is invalid. For an explanation of 

HIC numbers and suffixes please visit 

https://www.cahabagba.com/part_b/education_and_outreach/gen 

eral_billing_info/hic_suffixes.htm. 


Procedure code billed was for a diagnostic procedure such as an 

x-ray or lab work which requires the NPI of the ordering 



375 PAID AMOUNT CANNOT BE GREATER THAN 

ALLOWED AMOUNT 

Claim was submitted as Medicare Secondary Payer (MSP) and the 

primary paid amount submitted was greater than the primary allowed 

amount. 

Number of 

Claims 

1,668 

1,121 

Medicare B Newsline April 2012 11 

726 

596 

380

Mississippi Medicare Part B 















Rejection 


There was a problem involving HIPAA required loops, segments, or 

values. The specific loop will be identified, for example, 'ELEMENT 

N401 (D.E. 19) AT COL. 4 IS MISSING, THOUGH MARKED 

"MUST BE USED" (LOOP:2010BA POS:3140)'. The number after 

'POS' indicates the position in the file where the error occurred. If you 

need help locating specific positions in your 4010A1 file here is an 

article explaining one way you can do this: 

http://www.cahabagba.com/part_b/edi/hipaa_identifying_your_errors. 

htm. 



diagnosis code used. The invalid diagnosis code will appear inside the 

parenthesis. 

207 INVALID HIC NUMBER SUFFIX 

The suffix submitted for the beneficiary’s HIC number is invalid. For a 

list of valid suffixes and their meanings visit this article on our 

website; 

https://www.cahabagba.com/part_b/education_and_outreach/general_b 

illing_info/hic_suffixes.htm 


Procedure code billed was for a diagnostic procedure such as an x-ray 

or lab work which requires the NPI of the ordering physician, or a 

consultation, which requires the NPI of the referring physician, and 

this was not submitted on the claim 

202 RAILROAD 

The beneficiary’s HIC contains an alphabetic prefix, indicating that the 

patient is a Railroad Retiree. The claim should be submitted to 

Railroad Medicare. 

Number of 

Claims 

430 

Medicare B Newsline April 2012 12 

361 

141 

110 

95

Tennessee Medicare Part B 















Rejection 



diagnosis code used. The invalid diagnosis code will appear 

inside the parenthesis. 


Procedure code billed was for a diagnostic procedure such as an 

x-ray or lab work which requires the NPI of the ordering 






example, 'ELEMENT N401 (D.E. 19) AT COL. 4 IS MISSING, 

THOUGH MARKED "MUST BE USED" (LOOP:2010BA 

POS:3140)'. The number after 'POS' indicates the position in the 

file where the error occurred 

202 RAILROAD 

The beneficiary’s HIC (Medicare number) began with an 

alphabetic prefix, indicating the beneficiary s a Railroad retiree. 

302 INVALID BILLING (NO CHARGES BILLED) 

Claim did not contain any items with an associated billed 

amount. 

Number of 

Claims 

926 

702 

555 

449 

364 


Alabama Medicare Part B 

Top Ten EDI 277CA Edits for February 2012 for Version 5010 

For claim submissions in the 5010 format that pass high-level edits a 277CA transaction is created. This 

transaction will indicate file, batch, claim, and line level edits. 

For spreadsheets that list the 277CA edits and give more detailed information about them please visit the 

CMS website at http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp. Visit the Washington 

Publishing Company’s website at http://www.wpc-edi.com for more information about 277CA transactions 

and the codes used in them. 

In order to increase the number of claims that successfully pass through front-end editing and into 

processing Cahaba GBA EDI Services is providing you with the top ten 277CA edits. For the month of 

February 2012, these are: 

Production 

Edit Number 

Number of Edit 

Occurrences 

Business Edit 

Message 

X222.087.2010AA.NM109.050 8,692 This Claim is 

rejected for 

relational field due 

to Billing 

Provider's 

submitter not 

approved for 

electronic claim 

submissions on 

behalf of this 

Billing Provider. 

X222.351.2400.SV101-7.020 5,083 This Claim is 

rejected for 

relational field 

Information 

within the 

Detailed 

description of 

service. 

X222.196.2300.REF.010 4,094 This Claim is 

rejected for 


Information 

submitted 

inconsistent with 

billing guidelines 

for the Other 

Insured's Policy 

Explanation of 

Edit 

2010AA.NM109 

billing provider 

must be 

"associated" to the 

submitter (from a 

trading partner 

management 

perspective) in 

1000A.NM109. 

2400.SV101-7 

must be present. 

when 2400.SV101- 

2 is present on the 

table of procedure 

codes that require a 

description. 

2300.REF with 

REF01 = "F8" 

must not be 

present. 


Number. 

X222.295.2320.SBR03.006 4,094 This Claim is 

rejected for 


Information 

submitted 



for the Other 


Number. 

X222.094.2010AA.REF02.050 4,042 This Claim is 

rejected for 


Billing Provider's 

NPI (National 

Provider ID) and 

Tax ID. 


rejected for 

Invalid 

Information in the 


NPI (National 

Provider ID). 


rejected for 


Information 

within the 

HCPCS. 

X222.121.2010BA.NM109.020 2,312 This Claim is 

rejected for 

Invalid 

Information for a 

Subscriber's 

contract/member 

number. 

CSCC A8: 

"Acknowledgement 

/ Rejected for 

relational field in 

error" 

CSC 163: "Entity's 

Policy Number" 

CSC 732 

"Information 

submitted 


billing guidelines." 

EIC: GB "Other 

Insured" 

2010AA.REF must 

be associated with 

the provider 

identified in 

2010AA.NM109. 

2010AA.NM109 

must be a valid NPI 

on the Crosswalk 

when evaluated 

with 

1000B.NM109. 

When 

2400.SV101-1 = 

"HC", 

2400.SV101-2 

must be a valid 

HCPCS Code on 

the date in 

2400.DTP03 when 

DTP01 = "472". 

2010BA.NM109 

must be 10 - 11 

positions in the 

format of 

NNNNNNNNNA 

or 

NNNNNNNNNAA 

or 

NNNNNNNNNAN 

where “A” 

represents an alpha 


X222.273.2310C.N403.020 1,839 This Claim is 

rejected for 

Invalid 


Service Location's 

Postal/Zip. 

X222.262.2310B.NM109.030 1,701 This Claim is 

rejected for 

Invalid 


Rendering 

Provider's 

National Provider 

Identifier (NPI). 

character and “N” 

represents a 

numeric digit. 

2310C.N403 must 

be a valid 9 digit 

Zip Code. 

2310B.NM109 




with 

1000B.NM109. 


Georgia Medicare Part B 











Production: 

Edit Number 

Number of 

Edit 

Occurrences 

Business Edit 

Message 


rejected for 


to Billing Provider's 

submitter not 

approved for 





X999.DUPE 15,499 Rejected due to 

duplicate ST/SE 

submission. 

X222.351.2400.SV101-7.020. 5,657 This Claim is 

rejected for 


Information within 

the Detailed 


service. 


rejected for Invalid 


Subscriber's 


number. 


Edit 

2010AA.NM109 


must be 




management 


1000A.NM109. 

Exact duplicate of 

a previously 

submitted 

transaction set. 

2400.SV101-7 


when 2400.SV101- 




description. 

2010BA.NM109 

must be 10 - 11 


format of 

NNNNNNNNNA 

or 



rejected for 



NPI (National 


Tax ID. 

X222.295.2320.SBR03.006 3,221 This Claim is 

rejected for 


Information 

submitted 



for the Other 


Number. 

NNNNNNNNNAA 

or 

NNNNNNNNNAN 

where “A” 



represents a 




the provider 

identified in 

2010AA.NM109. 

CSCC A8: 

"Acknowledgement 

/ Rejected for 

relational field in 

error" 



CSC 732 

"Information 

submitted 


billing guidelines." 


Insured". 

X222.351.2400.SV103.020 3,089 This Claim is 


Information 

submitted 



for the Unit or 

Basis for 

Measurement 

Code.. 

2400.SV103 must 

be "MJ" when 

SV101-3, SV101- 

4, SV101-5, or 

SV101-6 is an 

anesthesia modifier 

(AA, AD, QK, QS, 

QX, QY or QZ). 

Otherwise, must be 

"UN". 


rejected for 



the HCPCS. 

When 

2400.SV101-1 = 

"HC", 

2400.SV101-2 


HCPCS Code on 

the date in 


DTP01 = "472". 

X222.087.2010AA.NM109.030 2,714 This Claim is 2010AA.NM109 


ejected for Invalid 



NPI (National 

Provider ID). 





Postal/Zip. 




with 

1000B.NM109. 

2310C.N403 must 


Zip Code. 


Mississippi Medicare Part B 











Production: 

Edit Number 

X222.087.2010AA.NM109. 

050 

X222.094.2010AA.REF02. 

050 

Number of 

Edit 

Occurrences 

Disposition/Error 

Code 

5,889 This Claim is rejected 

for relational field due 


submitter not approved 

for electronic claim 

submissions on behalf 

of this Billing Provider. 


for relational field 

Billing Provider's NPI 

(National Provider ID) 

and Tax ID. 

X222.273.2310C.N403.020 3,534 This Claim is rejected 

for Invalid Information 

for a Service Location's 

Postal/Zip. 

X222.136.2010BB.N403.02 

0 

X222.351.2400.SV101- 

7.020 



for a Payer's Postal/Zip 

Code. 



Information within the 

Detailed description of 

service. 

Explanation of Edit 

2010AA.NM109 

billing provider must 

be "associated" to the 



management 


1000A.NM109. 

2010AA.REF must be 

associated with the 

provider identified in 

2010AA.NM109. 

2310C.N403 must be a 

valid 9 digit Zip Code. 

2010BB.N403 must be 

a valid Zip Code. 

2400.SV101-7 must be 

present when 

2400.SV101-2 is 

present on the table of 

procedure codes that 

require a description. 


X222.087.2010AA.NM109. 

030 



in the Billing Provider's 

NPI (National Provider 

ID). 

X222.295.2320.SBR03.006 2,043 This Claim is rejected 


Information submitted 


billing guidelines for 

the Other Insured's 

Policy Number. 

X222.206.2300.REF02.020 1,608 This Claim is rejected 

for Invalid within the 

Information Care Plan 

Oversight Number's 

National Provider 

Identifier (NPI) and 

Care Plan Oversight 

Number. 

X222.403.2400.REF02.070 1,593 This Claim is rejected 


within the 

Authorization/certificat 

X222.351.2400.SV101- 

2.020 

ion number. 



Information within the 

HCPCS. 

2010AA.NM109 must 

be a valid NPI on the 

Crosswalk when 

evaluated with 

1000B.NM109. 

CSCC A8: 

"Acknowledgement / 

Rejected for relational 

field in error" 



CSC 732 "Information 

submitted inconsistent 

with billing 

guidelines." 


Insured" 

2300.REF02 must be 

valid according to the 

NPI algorithm. 

2400.REF02 must be a 

valid Mammography 

Certification Number. 

When 2400.SV101-1 = 

"HC", 2400.SV101-2 

must be a valid HCPCS 

Code on the date in 


DTP01 = "472". 


Tennessee Medicare Part B 











Production: 

Edit Number 

Number of 

Edit 

Occurrences 

Business Edit 

Message 


rejected for 



NPI (National 


Tax ID. 


rejected for 



submitter not 

approved for 






rejected for 



the Detailed 


service. 





Edit 



the provider 

identified in 

2010AA.NM109. 

2010AA.NM109 


must be 




management 


1000A.NM109. 

2400.SV101-7 


when 2400.SV101- 




description. 

2010BA.NM109 

must be 10 - 11 



Subscriber's 


number. 





NPI (National 

Provider ID). 


rejected for 



the HCPCS. 





Postal/Zip. 

X222.196.2300.REF.010 1,844 This Claim is 



the Payer Assigned 

Claim Control 

Number 

Information 

submitted 


billing guidelines. 

X222.262.2310B.NM109.030 1,655 This Claim is 



Rendering 

Provider's National 

Provider Identifier 

(NPI). 

format of 

NNNNNNNNNA 

or 

NNNNNNNNNAA 

or 

NNNNNNNNNAN 

where “A” 



represents a 


2010AA.NM109 




with 

1000B.NM109. 

When 

2400.SV101-1 = 

"HC", 

2400.SV101-2 


HCPCS Code on 

the date in 


DTP01 = "472". 

2310C.N403 must 


Zip Code. 

2300.REF with 

REF01 = "F8" 

must not be 

present. 

2310B.NM109 




with 

1000B.NM109. 

X222.305.2320.AMT.030 1,337 This Claim is If 2000B.SBR01 = 


ejected for Missing 


the Other payer's 


Benefits/payment 

information 

"S" then one 2320 

loop with an AMT 

segment with 

AMT01 = "D" 



Medicare Coverage Database (MCD) Article: Educational Article - 

Chiropractic Services - Retired 

J10 MAC B (Alabama, Georgia, Tennessee) (A51055) 

Carrier 00512 (Mississippi) (A51056) 

Effective March 31, 2012, the Medicare Coverage Database (MCD) Articles titled Educational Article – 

Chiropractic Services are retired. 

Effective April 1, 2012, please refer to the Local Coverage Determinations (LCDs) listed below for 

coverage guidance for chiropractic services: 

Medicine: Chiropractic Services (L32342) - J10 MAC B 

Medicine: Chiropractic Services (L32351) - Carrier 00512 

LCDs and Articles can be accessed from the Local Coverage Determinations (LCDs) and Articles page of 

our website (choose your state and select ‘Articles’). 


Local Coverage Determinations - Comment Period for Draft LCDs 

J10 MAC B (Alabama, Georgia, Tennessee) 

Carrier 00512 (Mississippi) 

The Comment Period for the Local Coverage Determinations (LCDs) listed below is from March 9, 2012 

through April 23, 2012: 

J10 MAC B 

Medicine: Noninvasive Peripheral Arterial and Venous Studies (DL30040) 

Transportation Services: Ambulance (DL30022) 

Carrier 00512 

Medicine: Noninvasive Peripheral Arterial and Venous Studies (DL30622) 

Transportation Services: Ambulance (DL32498) 

The Draft LCDs are accessible from the Cahaba GBA website at Local Coverage Determinations (LCDs) 

and Articles (select ‘Status of Draft LCDs’ for your state). 

Comments on the draft LCDs may be submitted via e-mail to: J10LCDComment@Cahabagba.com or in 

writing to the Medical Director at the address listed below. 

Cahaba Government Benefit Administrators®, LLC 

Comments for Draft LCDs 

ATTN: Contractor Medical Director (CMD) 

P.O. Box 13384 

Birmingham, AL 35202-3384 


Claim Specific CERT Errors- February 2012 

J10 MAC B (Alabama, Georgia, Tennessee) 

Carrier 00512 (Mississippi) 

The Comprehensive Error Rate Testing (CERT) Program was implemented by the Centers for Medicare & 

Medicaid Services (CMS) to monitor the accuracy of claims processing by Medicare contractors, like 

Cahaba. Contractors are then notified by CERT of the errors and findings. 

We would like to remind you that should you receive an Additional Documentation Request (ADR) such as 

a request for records to support services that are involved in a CERT review, you should submit the 

appropriate documentation to support the services billed, including but not limited to progress note(s) to 

match the DOS billed, lab results, operative reports, diagnostic tests, physician orders, etc. Medicare 

requires a legible identifier for services provided/ordered. The method used shall be hand written or an 

electronic signature (stamp signatures are not acceptable) to sign an order or other medical record 

documentation for medical review purposes. 

Providers may appeal unfavorable decisions with additional supporting documentation. For detailed 

information regarding the Appeals Process, refer to the following link: 

www.cahabagba.com/part_b/claims/appeals_process.htm. 

Please contact the Provider Contact Center for individual questions concerning CERT errors: 

Alabama, Georgia and Tennessee Providers – 1-877-567-7271 

Mississippi Providers – 1-866-419-9454 

This summary provides examples of Cahaba's errors identified by CERT. We encourage all providers to 

review this listing to educate you on common errors. This information will be updated periodically. The 

intent in providing this information is to prompt you to conduct an internal analysis of Medicare billing and 

reduce future denials by Medicare. 


News Flash Messages from CMS For All Part B Providers 

Extension of Enforcement Discretion Period for Updated HIPAA 5010 

Transaction Standards through June 30, 2012 

The Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) is 

announcing that it WILL NOT INITIATE enforcement action for an additional THREE (3) months, 

through June 30, 2012, against any covered entity that is required to comply with the updated transactions 

standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC 

X12 Version 5010 and NCPDP Versions D.0 and 3.0. 

On November 17, 2011, OESS announced that, for a 90-day period, it would not initiate enforcement action 

against any covered entity that was not compliant with the updated versions of the standards by the January 

1, 2012 compliance date. This was referred to as enforcement discretion, and during this period, covered 

entities were encouraged to complete outstanding implementation activities including software installation, 

testing and training. 

Health plans, clearinghouses, providers, and software vendors have been making steady progress: the 

Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 

percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. 

Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and 

some have made a full transition to Version 5010. 

Covered entities are making similar progress with Version D.0. At the same time, OESS is aware that there 

are still a number of outstanding issues and challenges impeding full implementation. OESS believes that 

these remaining issues warrant an extension of enforcement discretion to ensure that all entities can 

complete the transition. OESS expects that transition statistics will reach 98 percent industry wide by the 

end of the enforcement discretion period. 

Given that OESS will not initiate enforcement actions through June 30, 2012, industry is urged to 

collaborate more closely on appropriate strategies to resolve remaining problems. OESS is stepping up its 

existing outreach to include more technical assistance for covered entities. OESS is also partnering with 

several industry groups as well as Medicare FFS and Medicaid to expand technical assistance opportunities 

and eliminate remaining barriers. Details will be provided in a separate communication. 

The Medicare FFS program will continue to host separate provider calls to address outstanding issues related to 

Medicare programs and systems. The Medicare Administrative Contractors (MAC) will continue to work closely with 

clearinghouses, billing vendors, or healthcare providers requiring assistance in submitting and receiving Version 5010 

compliant transactions. 

The Medicaid program staff at CMS will continue to work with individual States regarding their program readiness. 

Issues related to implementation problems with the States may be sent to Medicaid5010@cms.hhs.gov. 

OESS strongly encourages industry to come together in a collaborative, unified way to identify and resolve all 

outstanding issues that are impacting full compliance, and looks forward to seeing extensive engagement in the 

technical assistance initiative to be launched over the next few weeks. 


HHS Announces Intent to Delay ICD-10 Compliance Date 

As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services 

Secretary Kathleen G. Sebelius announced that HHS will initiate a process to postpone the date by which 

certain health care entities have to comply with International Classification of Diseases, 10th Edition 

diagnosis and procedure codes (ICD-10). 

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of 

October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed 

rule. HHS will announce a new compliance date moving forward. 

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS 

Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns 

about the administrative burdens they face in the years ahead. We are committing to work with the provider 

community to reexamine the pace at which HHS and the nation implement these important improvements to 

our health care system.” 

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the 

exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities 

covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to 

use the ICD-10 diagnostic and procedure codes. 

Enrolling In the Medicare Program Fact Sheets 

Several fact sheets that provide education to specific provider types on how to enroll in the Medicare 

Program and maintain their enrollment information using Internet-based Provider Enrollment, Chain, and 

Ownership System (PECOS) have been recently updated and are available in downloadable format from the 

Medicare Learning Network® (MLN). Please visit 

http://www.CMS.gov/MedicareProviderSupEnroll/downloads/Medicare_Provider- 

Supplier_Enrollment_National_Education_Products.pdf for a complete list of all MLN products related to 

Medicare provider-supplier enrollment. 


Primary Care Incentive Payment (PCIP) program 

Per Section 5501(a) of the Affordable Care Act, the Primary Care Incentive Payment (PCIP) program 

authorizes an incentive payment of 10% of Medicare's program payments to be paid to qualifying primary 

care physicians and non-physician practitioners for services rendered from Sunday, January 1, 2011, to 

Thursday, December 31, 2015. CMS has published 22 Frequently Asked Question (FAQ) items related to 

the PCIP program. These new FAQs can be found here. Alternatively, these FAQ items can be found by 

visiting http://questions.CMS.hhs.gov/ and searching for “PCIP” or “Primary Care Incentive Payment.” 

Electronic Funds Transfer (EFT) 

Existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time of enrollment, enrollment change 

request or revalidation, providers and suppliers that expect to receive payment from Medicare for services 

provided must also agree to receive Medicare payments through Electronic Funds Transfer (EFT). Section 

1104 of the Affordable Care Act further expands Section 1862 (a) of the Social Security Act by mandating 

federal payments to providers and suppliers only by electronic means. As part of Medicare’s revalidation 

efforts, all suppliers and providers who are not currently receiving EFT payments will be identified, and 

required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application. For more 

information about provider enrollment revalidation, review the Medicare Learning Network’s Special 

Edition Article SE1126 titled, “Further Details on the Revalidation of Provider Enrollment Information” at 

http://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf. 

Revalidation Notice 

Has Medicare sent you a notice to revalidate your enrollment? If you are not sure, you can find lists of 

providers sent notices to revalidate their Medicare enrollment by scrolling to the "Downloads" section at 

http://www.CMS.gov/MedicareProviderSupEnroll/11_Revalidations.asp on the Centers for Medicare & 

Medicaid Services (CMS) website. That site currently contains links to lists of providers sent notices from 

September, 2011 through January, 2012. Information on revalidation letters sent in February will be posted 

in late March. For ease of reference, the lists are in order by National Provider Identifier and the date the 

notice was sent. 


News from CMS For Part B Providers 

Intensive Behavioral Therapy (IBT) for Obesity- Revised 

Note: This article was revised on March 9, 2012 to reflect the revised Change Request (CR) 7641 issued on 

March 7. In this article, the CR release date, transmittal number, and the Web address for accessing CR7641 

were revised. All other information is unchanged. 

Provider Types Affected 

This MLN Matters® article is intended for primary care physicians and other primary care practitioners 

billing Medicare contractors (carriers, Fiscal Intermediaries (FIs) and A/B Medicare Administrative 

Contractors (A/B MACs)) for services provided to Medicare beneficiaries in a primary care setting. 

Provider Action Needed 

This article is based on Change Request (CR) 7641, which informs Medicare contractors about 

implementing coverage of Intensive Behavioral Therapy (IBT) for obesity. 

Effective for claims with dates of service November 29, 2011, and later, Medicare beneficiaries with 

obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2, who are competent and alert 

at the time that counseling is provided and whose counseling is furnished by a qualified primary care 

physician or other primary care practitioner in a primary care setting, are eligible for: 

One face-to-face visit every week for the first month; 

One face-to-face visit every other week for months 2-6; and 

One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight 

loss requirement during the first 6 months. 

Medicare coinsurance and Part B deductible are waived for this service. 

See the ‘Background’ and ‘Additional Information’ sections of this article for further details regarding this 

change. Be sure your staffs are aware of this new coverage determination and that Healthcare Common 

Procedure Coding System (HCPCS) code G0447 (Face-to-Face Behavioral Counseling for Obesity, 15 

minutes) will be used to bill for these services. 

This code was effective November 29, 2011, and will appear in the January 2012 quarterly update of the 

Medicare Physician Fee Schedule Database (MPFSDB) and the Integrated Outpatient Code Editor (IOCE). 

Background 

Based upon authority in the Social Security Act to cover “additional preventive services” for Medicare 

beneficiaries if certain statutory requirements are met, and the services are reasonable and necessary for the 

prevention or early detection of illness or disability, the Centers for Medicare & Medicaid Services (CMS) 

initiated a new national coverage analysis on IBT for obesity. Screening for obesity in adults is a "B" 

recommendation by the U.S. Preventive Services Task Force (USPSTF) and is appropriate for individuals 

entitled to benefits under Medicare Part A and Part B. 


In 2003, the USPSTF found good evidence that BMI “is reliable and valid for identifying adults at increased 

risk for mortality and morbidity due to overweight and obesity.” The USPSTF also found fair to good 

evidence that high intensity counseling combined with behavioral interventions in obese adults (as defined 

by a BMI ≥30 kg/m2) “produces modest, sustained weight loss.” 

Effective for claims with dates of service on or after November 29, 2011, Medicare beneficiaries with 

obesity (BMI ≥30 kg/m2), who are competent and alert at the time that counseling is provided and whose 

counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary 

care setting are eligible for: 

One face-to-face visit every week for the first month; 

One face-to-face visit every other week for months 2-6; and 

One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight 

loss requirement during the first 6 months as discussed below. 

At the 6-month visit, a reassessment of obesity and a determination of the amount of weight loss should be 

performed. To be eligible for additional face-to-face visits occurring once a month for months 7-12, 

beneficiaries must have achieved a reduction in weight of at least 3kg (6.6 lbs.), over the course of the first 6 

months of intensive therapy. This determination must be documented in the physician office records for 

applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight 

loss of at least 3kg (6.6 lbs.) during the first 6 months of intensive therapy, a reassessment of their readiness 

to change and BMI is appropriate after an additional 6-month period. 

IBT for obesity consists of the following: 

1. Screening for obesity in adults using measurement of BMI calculated by dividing weight in 

kilograms by the square of height in meters (expressed kg/m2); 

2. Dietary (nutritional) assessment; and, 

3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through 

high intensity interventions on diet and exercise. 

Intensive behavioral intervention for obesity should be consistent with the 5-A framework: 

1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change 

goals/methods. 

2. Advise: Give clear, specific, and personalized behavior change advice, including information about 

personal health harms and benefits. 

3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s 

interest in and willingness to change the behavior. 


4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving 

agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for 

behavior change, supplemented with adjunctive medical treatments when appropriate. 

5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing 

assistance/support and to adjust the treatment plan as needed, including referral to more intensive or 

specialized treatment. 

Billing Requirements 

Diagnostic Codes 

Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS 

code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes. G0447 must be billed along with 

1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45). The type of service (TOS) 

for G0447 is 1. (ICD-10 codes will be Z68.30-Z68.39.9, Z68.41- Z68.45) 

Effective for claims with dates of service on or after November 29, 2011, Medicare contractors will deny 

claims for HCPCS G0447 that are not submitted with the appropriate diagnostic code (V85.30-V85.39, 

V85.41-V85.45). 

Claims submitted with HCPCS G0447 that are not submitted with these diagnosis codes will be denied with 

the following messages: 

Claim Adjustment Reason Code (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." 

Remittance Advice Remark Code (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." 

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: Per MLN Matters® article MM7228, when modifier GZ is used, contractors will use CARC 50 

(These services are non-covered services because this is not deemed a “medical necessity” by the payer.). 

This is true with all denials noted below that have the Group Code CO. MM7228 may be found at 

http://www.cms.gov/MLNMattersArticles/downloads/MM7228.pdf on the CMS website. 

Specialty Codes 

Effective for services on or after November 29, 2011, Medicare will pay claims for G0447, only when 

services are submitted by the following provider specialty types found on the provider’s Medicare 

enrollment record: 


01 - General Practice 

08 - Family Practice 

11 - Internal Medicine 

16 - Obstetrics/Gynecology 

37 - Pediatric Medicine 

38 - Geriatric Medicine 

50 - Nurse Practitioner 

89 - Certified Clinical Nurse Specialist 

97 - Physician Assistant 

If your specialty type is not one of the above, your claim will be denied using the following codes: 

CARC of 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.)," 

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


claim is received with a GA modifier indicating a signed ABN is on file), and 

Group Code CO (Contractual Obligation), assigning financial liability to the provider (if a claim is 


Place of Service (POS) Codes 

Effective for services on or after November 29, 2011, Medicare will pay for obesity counseling claims 

containing HCPCS G0447 only when services are provided with the following POS codes: 

11 - Physician’s Office 

22 - Outpatient Hospital 

49 - Independent Clinic 

71 - State or local public health clinic. 

Line items on claims for G0447 will be denied if not performed in these POSs using the following codes: 

CARC 58 – "Treatment was deemed by the payer to have been rendered in an inappropriate or invalid POS. 

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." 

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)and 

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). 


Frequency Limitation 

Effective July 2, 2012, for claims processed with dates of service on or after November 29, 2011, Medicare 

will pay for G0447 with an ICD-9 code of V85.30-V85.39, V85.41-V85.45, no more than 22 times in a 12- 

month period. Line items on claims beyond the 22 limit will be denied using the following codes: (Note: 

When applying this frequency limitation, a claim for the professional service and a claim for a facility 

fee will be allowed.) 

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." 


claim is received with a GA modifier indicating a signed ABN is on file), and 



Note: Your contractor will not search their files for claims that may have been paid in error. However, 

contractors may adjust claims that are brought to their attention. 

Institutional Claims Notes 

Claims submitted with either a Type of Bill (TOB) 13X or TOB 85X (where the revenue code is not 096X, 

097X, or 098X) will be identified as facility fee service claims. 

Claims submitted with TOBs 71X, 77X, or 85X (where the revenue code is 096X, 097X, or 098X) will be 

identified as professional service claims. 

Medicare will pay for G0447 on institutional claims in hospital outpatient departments TOB 13X based on 

OPPS and in Critical Access Hospitals TOB 85X based on reasonable cost. 

The CAH Method II payment is for G0447 with revenue codes 096X, 097X, or 098X is based on 115% of 

the lesser of the fee schedule amount or submitted charge. Deductible and coinsurance do not apply. 

Medicare will line-item deny any claim submitted with G0447 when the TOB is not 13X, 71X, 77X, or 85X 

with the following: 

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." 


claim is received with a GA modifier indicating a signed ABN is on file) and 




Note: Medicare will hold institutional claims received before July 2, 2012, with TOBs 13X, 71X, 77X, and 

85X reporting G0447. 

Rural Health Clinics and Federally Qualified Health Centers Claims Notes 

Rural Health Clinics, using TOB 71X, and Federally Qualified Health Centers, using TOB 77X, must 

submit HCPCS code G0447 on a separate service line to ensure coinsurance and deductible are not appliced 

to this service. Such claims will be paid based on the all-inclusive payment rate. 

For RHC and FQHC services that contain HCPCS code G0447 with another encounter/visit with the same 

line item DOS, the service line with HCPCS G0447 will be denied with the following messages: 

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" and 

Group Code CO (Contractual Obligation) 

Note: Obesity counseling is not separately payable with another encounter/visit on the same day. This does 

not apply for Initial Preventive Physical Examination (IPPE) claims, claims containing modifier 59, and 

77X claims containing Diabetes Self-Management Training and Medical Nutrition Therapy services. 

Additional Information 

The official instruction, CR7641, issued to your FI, carrier, and A/B MAC regarding this change, was issued 

in 2 transmittals at http://www.cms.gov/transmittals/downloads/R2421CP.pdf and 

http://www.cms.gov/transmittals/downloads/R142NCD.pdf on the CMS website. 

MLN Matters® MM7641 


Instructions for Processing Form CMS-855O Submissions 


This MLN Matters® Article is intended for physicians and non-physician practitioners who submit a Form 

CMS-855O for the sole purpose of ordering and referring items and/or services to beneficiaries in the 

Medicare program. 

What You Need To Know 

This article is based on Change Request (CR) 7723, which furnishes instructions to Medicare contractors 

(carriers and Medicare Administrative Contractors (A/B MACs)) regarding the processing of Form CMS- 

855O submissions. Specific topics in CR 7723 include, but are not limited to: (1) initial applications, (2) 

changes of information, and (3) revocations. Model letters that Medicare contractors will use in 

communicating with providers on these issues are also provided in CR7723, which is available at 

http://www.cms.gov/Transmittals/downloads/R410PI.pdf on the Centers for Medicare & Medicaid Services 

(CMS) website. 

Background 

Generally, depending upon State law, the following physicians and non-physician practitioners are 

permitted to order or refer items or services for Medicare beneficiaries: 

Doctors of medicine or osteopathy; 

Doctors of dental surgery or dental medicine; 

Doctors of podiatry; 

Doctors of optometry; 

Physician assistants; 

Certified clinical nurse specialists; 

Nurse practitioners; 

Clinical psychologists; 

Certified nurse midwives; and 

Clinical social workers. 

Most physicians and non-physician practitioners enroll in Medicare so they can receive reimbursement for 

covered services to Medicare beneficiaries. However, some physicians and non-physician practitioners who 

are not enrolled in Medicare via the Form CMS-855I may wish to order or refer items or services for 

Medicare beneficiaries. These individuals can become eligible to do so by completing the Form CMS-855O 

via paper or the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) process. 

It is important to note that physicians and non-physician practitioners that complete the Form CMS-855O do 

not and will not send claims to a Medicare contractor for services they furnish. They are not afforded 

Medicare billing privileges for the purpose of submitting claims to Medicare directly for services that they 

furnish to beneficiaries. 

Key Points of CR7723 

Upon receipt of an initial Form CMS-855O or a Form CMS-855O change of information request (or 

a certification statement for PECOS submissions), the Medicare contractor shall pre-screen the form. 


Unless stated otherwise in another CMS directive, the contractor shall verify all of the information 

on an initial Form CMS-855O submission. 

If, at any time during the pre-screening or verification process for an initial Form CMS-855O 

submission or a Form CMS-855O change of information request, the contractor needs additional or 

clarifying information from the supplier, it shall follow existing CMS instructions for obtaining this 

data. 

Upon completion of its review of an initial Form CMS-855O submission or a Form CMS-855O 

change of information request, the contractor shall approve, deny, or reject the submission. 

The contractor shall reject an initial Form CMS-855O submission or a Form CMS-855O change of 

information request, if the supplier fails to furnish all required information on the form within 30 

calendar days of the contractor’s request to do so. 

When denying or rejecting a Form CMS-855O submission, the contractor shall: (1) switch the 

PECOS record to a “denied” or “rejected” status (as applicable), and (2) send a letter to the supplier 

notifying him or her of the denial or rejection and the reason(s) for it. 

For suppliers whose Form CMS-855O submissions are approved, the contractor shall treat the 

supplier as a non-participating supplier. 

If the contractor approves an initial Form CMS-855O submission, the contractor shall: (1) switch the 

PECOS record to an “approved” status, and (2) send a letter (via mail or e-mail) to the supplier 

notifying him or her of the approval. 

If the contractor determines that grounds exist for revoking a supplier’s Form CMS-855O 

enrollment, it shall: (1) switch the supplier’s PECOS record to a “revoked” status, (2) end-date the 

PECOS record, and (3) send a letter to the supplier stating that his or her Form CMS-855O 

enrollment has been revoked. 


The official instruction, CR 7723 issued to your carrier or A/B MAC regarding this change may be viewed 

at http://www.cms.gov/Transmittals/downloads/R410PI.pdf on the CMS website. 



Use of Revised Remittance Advice Remark Code (RARC) N103 When 

Denying Services Furnished to Federally Incarcerated Beneficiaries - 

Revised 

Note: This article was revised on March 9, 2012 to reflect the revised CR7678 issued on March 7. In this 

article, the CR release date, transmittal number, and the Web address for accessing CR7678 were revised. 

All other information is the same. 


Providers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, A/B Medicare 

Administrative Contractors (MACs) and Durable Medical Equipment MACs or DME MACs) for Medicare 

beneficiaries who are incarcerated in a Federal facility. 

Provider Action Needed 

This article is based on Change Request (CR) 7678 which informs Medicare contractors that the Centers for 

Medicare & Medicaid Services (CMS) is amending Remittance Advice Remark Code (RARC) N103 to 

include language that further explains the newly modified RARC N103—denying claims for services to 

federally incarcerated beneficiaries. 

CR7678 is limited to providers billing for services for beneficiaries while they are in Federal, State, or local 

custody and the goal of this CR7678 is to be more specific in explaining the accompanying adjustment. 

See the ‘Background’, ‘Key Points’, and ‘Additional Information’ sections of this article for details 

regarding these changes. 

Background 

The following exclusions presumptively apply to individuals who are incarcerated in a Federal facility under 

Federal authority: 

According to Federal regulations at 42 Code of Federal Regulations (CFR) Section 411.4 Medicare 

does not pay for services furnished to a beneficiary who has no legal obligation to pay for the service 

and no other person or organization has a legal obligation to provide or pay for the service; 

Under 42 CFR 411.6, Medicare does not pay for services furnished by a federal provider of services 

or by a federal agency; and 

Under 42 CFR 411.8, Medicare does not pay for services that are paid for directly or indirectly by a 

governmental entity. 

Key Points 

When denying claims for services furnished to federally incarcerated Medicare beneficiaries, the newly 

modified RARC N103 will be used (in addition to remittance advice language already in use) and it reads as 

follows: 

“Social Security records indicate that this patient was a prisoner when the service was rendered. This payer 

does not cover items and services furnished to an individual while he or she is in a Federal facility, or while 


he or she is in State or local custody under a penal authority, unless under State or local law, the individual 

is personally liable for the cost of his or her health care while incarcerated and the State or local government 

pursues such debt in the same way and with the same vigor as any other debt.” 


The official instruction, CR7678, issued to your Medicare contractors (FIs, A/B MACs, DME MACs, and 

carriers) regarding this change, may be viewed at 

http://www.cms.gov/Transmittals/downloads/R1054OTN.pdf on the CMS website. 

If you have any questions, please contact your Medicare contractor at their toll-free number, which may be 

found at http://www.cms.gov/MLNProducts/. 



Medicare B Newsline Quality Survey 

Please take a moment to let us know your thoughts regarding this issue of the Medicare B Newsline. 

Your Name (optional): 

Telephone Number (optional): 

1. Usefulness of the information. 

Please rate the publication by circling the number of your choice. 

(10 = Excellent, 5 = Satisfactory, 1 = Unacceptable) 

1 2 3 4 5 6 7 8 9 10 

2. Organization and layout of the information. 

1 2 3 4 5 6 7 8 9 10 

3. Design and physical appearance of the publication. 

1 2 3 4 5 6 7 8 9 10 

4. Value of Medicare A Newsline as a reference item. 

1 2 3 4 5 6 7 8 9 10 

5. Do you use the website to obtain copies of the Medicare newsletter? 

Yes 

No 

6. What can we do to make Medicare B Newsline a more effective publication? 

Thank you for your time. You can email your response by clicking SUBMIT. 

Fax or mail your response to: 

Cahaba Government Benefit Administrators, LLC 

Provider Outreach and Education 

PO Box 12967 

Birmingham, Alabama 35202 

Fax: 205 220-1531 

Medicare B Newsline

Medicare Part B Newsline April 2012 - Cahaba GBA

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