N517, N519, CARC 149 and N587 - Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes

Effective for dates of service on or after September 27, 2013, contractors shall return as unprocessable/return to provider claims for PET Aß imaging, through CED during a clinical trial, not containing the following:


• Condition code 30, (A/B MAC (A) only)

• Modifier Q0 and/or modifier Q1 as appropriate

• ICD-9 dx code V70.7/ICD-10 dx code Z00.6 (on either the primary/secondary position)

• A PET HCPCS code (78811 or 78814)

• At least, one Dx code from the table below,


ICD-9 Codes                                                 Corresponding ICD-10 Codes

290.0 Senile dementia, uncomplicated                                       F03.90 Unspecified dementia without behavioral disturbance

290.10 Presenile dementia, uncomplicated                                 F03.90   Unspecified dementia without behavioral disturbance

290.11 Presenile dementia with delirium                                      F03.90    Unspecified dementia without behavioral disturbance

290.12 Presenile dementia with delusional features                      F03.90    Unspecified dementia without behavioral disturbance

290.13 Presenile dementia with depressive features                    F03.90    Unspecified dementia without behavioral disturbance

290.20 Senile dementia with delusional features                          F03.90    Unspecified dementia without behavioral disturbance

290.21 Senile dementia with depressive features                         F03.90    Unspecified dementia without behavioral disturbance

290.3 Senile dementia with delirium                                            F03.90    Unspecified dementia without behavioral disturbance

290.40 Vascular dementia, uncomplicated                                   F01.50    Vascular dementia without behavioral disturbance

290.41 Vascular dementia with delirium                                       F01.51      Vascular dementia with behavioral disturbance

290.42 Vascular dementia with delusions                                     F01.51       Vascular dementia with behavioral disturbance

290.43 Vascular dementia with depressed mood                         F01.51          Vascular dementia with behavioral disturbance

294.10 Dementia in conditions classified elsewhere without
behavioral disturbance                                                                F02.80  Dementia in other diseases classified elsewhere without                                                                                                  behavioral disturbance

294.11 Dementia in conditions classified elsewhere with
behavioral disturbance                                                               F02.81     Dementia in other diseases classified elsewhere with                                                                                                behavioral disturbance

294.20 Dementia, unspecified, without behavioral disturbance         F03.90     Unspecified dementia without behavioral disturbance

294.21 Dementia, unspecified, with behavioral disturbance            F03.91       Unspecified dementia with behavioral disturbance

331.11 Pick’s Disease                                                                G31.01 Pick's disease


331.19 Other Frontotemporal dementia                                     G31.09 Other frontotemporal dementia

331.6 Corticobasal degeneration                                              G31.85 Corticobasal degeneration

331.82 Dementia with Lewy Bodies                                          G31.83 Dementia with Lewy bodies

331.83 Mild cognitive impairment, so stated                              G31.84 Mild cognitive impairment, so stated


780.93 Memory Loss                                                                  R41.1 Anterograde amnesia
                                                                                                 R41.2 Retrograde amnesia
                                                                                                 R41.3 Other amnesia (Amnesia NOS, Memory loss NOS)

V70.7 Examination for normal comparison or control in clinical         Z00.6   Encounter for examination for normal comparison and                                                                                                   control in clinical research program


and
• Aß HCPCS code A9586 or A9599

Contractors shall return as unprocessable claims for PET Aß imaging using the following messages:

-Claim Adjustment Reason Code 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing.

Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

-Remittance Advice Remark Code N517 - Resubmit a new claim with the requested information.

- Remittance Advice Remark Code N519 - Invalid combination of HCPCS modifiers.

Contractors shall line-item deny claims for PET Aß , HCPCS code A9586 or A9599 , where a previous PET Aß, HCPCS code A9586 or A9599 is paid in history using the following messages:

• CARC 149: “Lifetime benefit maximum has been reached for this service/benefit category.”

• RARC N587: “Policy benefits have been exhausted”.

• MSN 20.12: “This service was denied because Medicare only covers this service once a lifetime.”

• Spanish Version: “Este servicio fue negado porque Medicare sólo cubre este servicio una vez en la vida.”

• Group Code: PR, if a claim is received with a GA modifier

• Group Code: CO, if a claim is received with a GZ modifier