Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes
Effective for dates of service on or after April 3, 2009, contractors shall return as unprocessable/return to provider claims that do not include the PI modifier with one of the PET/PET/CT Procedure codes listed in subsection C. above when billing for the initial treatment strategy for solid tumors in accordance with Pub.100-03, NCD Manual, section 220.6.17.
In addition, contractors shall return as unprocessable/return to provider claims that do not include the PS modifier with one of the Procedure codes listed in subsection C. above when billing for the subsequent treatment strategy for solid tumors in accordance with Pub.100-03, NCD Manual, section 220.6.17.
The following messages apply:
• Claim Adjustment Reason Code (CARC) 4 – The procedure code is inconsistent with the modifier used or a required modifier is missing.
• Remittance Advice Remark Code (RARC) MA-130 – Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.
• RARC M16 – Alert: See our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.
Effective for claims with dates of service on or after April 3, 2009, through June 10, 2013, contractors shall return as unprocessable/return to provider FDG PET claims billed to inform initial treatment strategy or subsequent treatment strategy when performed under CED without one of the PET/PET/CT Procedure codes listed in subsection C. above AND modifier PI OR modifier PS AND a cancer diagnosis code AND modifier Q0/Q1.
The following messages apply to return as unprocessable claims:
• CARC 4 – The procedure code is inconsistent with the modifier used or a required modifier is missing.
• RARC MA-130 – Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.
• RARC M16 – Alert: See our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.
Effective April 3, 2009, contractors shall deny claims with ICD-9/ICD-10 diagnosis code 185/C61 for FDG PET imaging for the initial treatment strategy of patients with adenocarcinoma of the prostate.
For dates of service prior to June 11, 2013, contractors shall also deny claims for FDG PET imaging for subsequent treatment strategy for tumor types other than breast, cervical, colorectal, esophagus, head and neck (non-CNS/thyroid), lymphoma, melanoma, myeloma, non-small cell lung, and ovarian, unless the FDG PET is provided under CED (submitted with the Q0/Q1 modifier) and use the following messages:
• Medicare Summary Notice 15.4 – Medicare does not support the need for this service or item
• CARC 50 – These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
• Contractors shall use Group Code CO (Contractual Obligation)
If the service is submitted with a GA modifier indicating there is a signed Advance Beneficiary Notice (ABN) on file, the liability falls to the beneficiary. However, if the service is submitted with a GZ modifier indicating no ABN was provided, the liability falls to the provider.
