US · guidance
CMS Pub. 100-04, ch. 14, § 60.3
Applicable ASC Messages for Certain Payment Indicators
Effective for Services Performed on or after January 1, 2009
(Rev. 11793; Issued:01-19-23; Effective: 02-21-23; Implementation: 02-21-23)
Contractors shall deny services for HCPCS codes with payment indicators C5 (Inpatient
surgical procedure under the OPPS; no payment made.), M6 (No payment made; paid
under another fee schedule), U5 (Surgical unlisted service excluded from ASC payment.
No payment made.), or X5 (Unsafe surgical procedure in ASC. No payment made).
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 Four.
Group Code: CO
CARC: 5
RARC: N/A
MSN: 16.32
Contractors shall deny services for CPT codes with payment indicators E5 (Surgical
procedure/item not valid for Medicare purposes because of coverage, regulation and/or
statute; no payment made), or Y5 (Non-surgical procedure/item not valid for Medicare
purposes because of coverage, regulation and/or statute; no payment made).
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: PR
CARC: 96
RARC: N425
MSN: 16.10
NOTE: Contractors shall assign beneficiary liability for facility charges HCPCS codes
billed with ASC payment indicators C5, E5, U5 and X5.
Contractors return as unprocessable services for HCPCS codes with payment indicator
D5 (Deleted/discontinued code; no payment made).
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: 181
RARC: N56
MSN: N/A
Contractors shall deny services for HCPCS with payment indicators L1 (Influenza
vaccine; pneumococcal vaccine, Covid-19 Vaccine, monoclonal antibody therapy
product. Packaged item/service; no separate payment made), NI (Packaged service/item;
no separate payment made) or S1 (Service not surgical in nature; and not a radiology
service payable under the OPPS, drug/biological, or brachytherapy source. Packaged
item/service; no separate payment made).
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 Four.
Group Code: CO
CARC: 97
RARC: N390
MSN: 16.32
Contractors shall return as unprocessable services for HCPCS with payment indicators
B5 (Alternative code may be available; no payment made).
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: 16
RARC: M51
MSN: N/A
History
(Rev. 11793; Issued:01-19-23; Effective: 02-21-23; Implementation: 02-21-23)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
f1e302e78e062f51dbc47d10ed271e6dbc531faa179111fae753e94458956125
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