CMS Pub. 100-04, ch. 1, § 80.3.2.1.3

Specialties/Services

(Rev. 3510, Issued: 04-29-16, Effective: 10-01-16, Implementation; 10-03-16)

Unless otherwise specified, the contractor shall use the following remittance advice

messages and associated codes when rejecting/denying claims under the policies in this

section. These CARC/RARC combinations compliant with CAQH CORE Business

Scenario Two.

Group Code: CO

CARC: 16

RARC: shown below.

MSN: N/A

A/B MACs (B) must return the following claim as unprocessable to the provider of

service/supplier:

A. For chiropractor claims:

1. If the x-ray date is not entered in item 19 for claims with dates of service prior to

January 1, 2000. Entry of an x-ray date is not required for claims with dates of

service on or after January 1, 2000.

2. If the initial date “actual” treatment occurred is not entered in item 14. RARC:

MA122

B. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA)

claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or

ASC) and the group’s name, address, and ZIP Code is not entered in item 33 or if the NPI

is not entered in item 33a of the Form CMS-1500, if their personal NPI is not entered in

item 24J of the Form CMS-1500. RARC: MA112

C. For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP

Code of the location where the order was accepted were not entered in item 32. RARC:

MA114

D. For physicians who maintain dialysis patients and receive a monthly capitation

payment:

1. If the physician is a member of a professional corporation, similar group, or

clinic, and the NPI is not entered into item 24J of the Form CMS-1500. RARC: N290

2. If the name, address, and ZIP Code of the facility other than the patient’s home or

physician’s office involved with the patient’s maintenance of care and training is not

entered in item 32. RARC: MA114. Effective for claims received on or after April 1,

2004, the name, address, and ZIP Code of the service location for all services other

than those furnished in place of service home – 12 must be entered.

E. For routine foot care claims, if the date the patient was last seen (RARC: N324) and

the attending physician’s NPI is not present in item 19 (RARC: N253).

F. For immunosuppressive drug claims, if a referring/ordering physician, physician’s

assistant, nurse practitioner, clinical nurse specialist was used and their name is not

present in items 17 or 17a. (RARC: N264), or if the NPI is not entered in item 17b. of the

Form CMS-1500 (RARC: N286).

G. For all laboratory services, if the services of a referring/ordering physician,

physician’s assistant, nurse practitioner, clinical nurse specialist are used and his or her

name is not present in items 17 or in 17a. (RARC: N264) or if the NPI is not entered in

item 17b. of the Form CMS-1500 (RARC: N286).

H. For laboratory services performed by a participating hospital-leased laboratory or

independent laboratory in a hospital, clinic, laboratory, or facility other the patient’s

home or physician’s office (including services to a patient in an institution), if the name,

address, and ZIP Code of the location where services were performed is not entered in

item 32. RARC: MA114 Effective for claims received on or after April 1, 2004, the

name, address, and ZIP Code of the service location for all services other than those

furnished in place of service home – 12 must be entered.

I. For independent laboratory claims:

1. Involving EKG tracing and the procurement of specimen(s) from a patient at

home or in an institution, if the claim does not contain a validation from the

prescribing physician that any laboratory service(s) performed were conducted at

home or in an institution by entering the appropriate annotation in item 19 (i.e.,

“Homebound”). RARC: MA116

2. If the name, address, and ZIP Code where the test was performed is not entered in

item 32, if the services were performed in a location other than the patient’s home or

physician’s office. RARC: MA114. Effective for claims received on or after April 1,

2004, the name, address, and ZIP Code of the service location for all services other

than those furnished in place of service home – 12 must be entered.

3. When a diagnostic service is billed as an anti-markup service and the service is

purchased from another billing jurisdiction, the billing physician or supplier must

submit the name, address, and ZIP Code of the performing physician or supplier in

Item 32, and the NPI of the performing physician or supplier in Item 32a. If Items 32

and 32a are not entered. RARC: MA114

J. For mammography “diagnostic” and “screening” claims, if a qualified screening

center does not accurately enter their 6-digit, FDA-approved certification number in item

32 when billing the technical or global component. RARC: MA128

K. For parenteral and enteral nutrition claims, if the services of an ordering/referring

physician, physician assistant, nurse practitioner, clinical nurse specialist are used and

their name is not present in item 17 (RARC: N264) or if the NPI is not entered in item

17b. of the Form CMS-1500(RARC: N286).

L. For portable x-ray services claims, if the ordering physician, physician assistant,

nurse practitioner, clinical nurse specialist’s name, and/or NPI is not entered in items 17

(RARC: N264) or if the NPI is not entered in item 17b. of the Form CMS-1500 (RARC:

N286).

M. For radiology and pathology claims for hospital inpatients, if the referring/ordering

physician, physician assistant, nurse practitioner, or clinical nurse specialist’s name, if

appropriate, is not entered in item 17 (RARC: N264) or if the NPI is not entered in item

17b. of the Form CMS-1500 (RARC: N286).

N. Effective for claims with dates of service on or after October 1, 2012, all claims for

physical therapy, occupational therapy, or speech-language pathology services, including

those furnished incident to a physician or nonphysician practitioner (NPP) services, must

have the name and NPI of the certifying physician or NPP of the therapy plan of care.

For the purposes of processing professional claims, the certifying physician/NPP is

considered a referring provider. For paper billing, the certifying physician/NPP name

and NPI is entered in Items 17 and 17b. Providers and suppliers filing electronic claims

are required to comply with applicable HIPAA ASC X12 837 claim completion

requirements for reporting a referring provider. (See Pub. 100-04, chapter 5, §20 and

Pub. 100-02, chapter 15, §§220 and 230 for therapy service policies.)

NOTE: For items 80.3.2.1.3 (g), (k), (l), (m), and (n) above, effective for claims with

dates of services (DOS) on or after the implementation date of the Phase 2 ordering and

referring denial edits, the Part B clinical lab and imaging technical or global component

claim, or Durable Medical Equipment, Prosthetics, and Orthotics Suppliers (DMEPOS)

claim is denied due to the ordering/referring provider not allowed to order/refer.

For item N only: The contractor shall use the following remittance advice messages and

associated codes when rejecting/denying claims under this policy. This CARC/RARC

combination is compliant with CAQH CORE Business Scenario Three.

Group Code: CO

CARC: 183

RARC: N574

MSN: N/A

The claim is denied when the first four letters of the last name provided on the

ordering/referring provider’s claim does not match what is listed in the provider’s record.

RARC: N264

If the claim is submitted that lists an ordering/referring provider and the required

matching NPI is not reported, then the claim shall be rejected. This is the only instance

when a rejection is allowed. RARC: N256.

O. For all laboratory work performed outside a physician’s office, if the claim does not

contain a name, address, and ZIP Code for where the laboratory services were performed

in item 32 or if the NPI is not entered into item 32a of the Form CMS-1500 if the services

were performed at a location other than the place of service home – 12. RARC: MA114

P. For all physician office laboratory claims, if a 10-digit CLIA laboratory identification

number is not present in item 23. This requirement applies to claims for services

performed on or after January 1, 1998. RARC: MA120

Q. For investigational devices billed in an FDA-approved clinical trial if an

Investigational Device Exemption (IDE) number is not present in item 23, for dates of

service through March 31, 2008. RARC: MA50. With the use of new modifier Q0,

effective for dates of service on and after April 1, 2008, contractors will no longer be able

to distinguish an IDE claim from other investigational clinical services. Therefore this

edit will no longer apply.

R. For physicians performing care plan oversight services if the 6-digit Medicare

provider number of the home health agency (HHA) or hospice is not present in item 23.

S. For Competitive Acquisition Program drug and biological claims, in accordance with

the instructions found in the Medicare Claims Processing Manual, chapter 17, section

100.2.1 – section 100.9.

T. For claims for artificial hearts covered by Medicare under an approved clinical trial,

if procedure code 0051T is entered in Item 24D, and an 8-digit clinical trial number that

matches an approved clinical trial listed at:

http://www.cms.hhs.gov/MedicareApprovedFacilitie/06_artificialhearts.asp#TopOfPage

is not entered in Item 19; and the HCPCS modifier Q0 is not entered on the same line as

the procedure code in Item 24D, and the diagnosis code V70.7 (if ICD-9-CM is

applicable) or Z00.6 (if ICD-10-CM is applicable) is not entered in Item 21 and linked to

the same procedure code.

For item T only: The contractor shall use the following remittance advice messages and

associated codes when rejecting/denying claims under this policy. This CARC/RARC

combination is compliant with CAQH CORE Business Scenario Two.

Group Code: CO

CARC: 4

RARC: N/A

MSN: N/A

U. For clinical trial claims processed after September 28, 2009, with dates of service

on or after January 1, 2008, claims submitted with either the modifier QV or the modifier

Q1, if the diagnosis code V70.7 (if ICD-9-CM is applicable) or Z00.6 (if ICD-10-CM is

applicable) is not submitted with the claim.

V. For ambulance claims, claims submitted without the ZIP Code of the loaded

ambulance trip’s point-of-pickup in Item 23 of the CMS-1500 Form.