CMS Pub. 100-04, ch. 18, § 180.4

Group Codes, and Medicare Summary Notice Messages

(Rev. 2433, Issued: 03-26-12, Effective: 10-14-11, Implementation: 12-27-11 non-system changes, 04-02-12 shared system changes, 07-02-12 CWF/HICR/MCS MCSDT)

A/B MACs (A) and (B) shall use the appropriate claim adjustment reason codes (CARCs),

remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN)

messages when denying payment for alcohol misuse screening and alcohol misuse behavioral

counseling sessions:

• For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code

G0442 and alcohol misuse counseling HCPCS code G0443 with another encounter/visit

with the same line item date of service, use group code CO and reason code:

o 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

• Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a

TOB other than 13X, 71X, 77X, and 85X:

o Claim Adjustment Reason Code (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

o Remittance Advice Remark Code (RARC) M77 - Missing/incomplete/invalid place of

service

o Group Code PR (Patient Responsibility) assigning financial liability to the

beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on

file.

o 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.

• Denying claims that contains more than one alcohol misuse behavioral counseling session

G0443 on the same date of service:

o Medicare Summary Notice (MSN) 15.6 - The information provided does not support

the need for this many services or items within this period of time.

o Claim Adjustment Reason Code (CARC) 151 - Payment adjusted because the payer

deems the information submitted does not support this many/frequency of services.

o Remittance Advice Remark Code (RARC) M86 - Service denied because payment

already made for same/similar procedure within set time frame.

o Group Code PR (Patient Responsibility) assigning financial liability to the

beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on

file.

o 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.

• Denying claims that are not submitted from the appropriate provider specialties:

o Medicare Summary Notice (MSN) 21.18 - This item or service is not covered when

performed or ordered by this provider.

o Claim Adjustment Reason Code (CARC) 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.

o Remittance Advice Remark Code (RARC) N95 - This provider type/provider

specialty may not bill this service.

o Group Code PR (Patient Responsibility) assigning financial liability to the

beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on

file.

o 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.

• Denying claims without the appropriate POS code:

o Medicare Summary Notice (MSN) 21.25 - This service was denied because Medicare

only covers this service in certain settings.

o Claim Adjustment Reason Code (CARC) 58 - Treatment was deemed by the payer to

have been rendered in an inappropriate or invalid place of service. Note: Refer to the

835 Healthcare Policy Identification Segment (loop 2110 Service Payment

Information REF) if present.

o Remittance Advice Remark Code (RARC) N428 - Not covered when performed in

this place of service.

o Group Code PR (Patient Responsibility) assigning financial liability to the

beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on

file.

o 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.

• Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a

12-month period, and denying alcohol misuse counseling sessions HCPCS code G0443

more than four times in the same 12-month period:

o Medicare Summary Notice (MSN) 20.5 - These services cannot be paid because your

benefits are exhausted at this time.

o Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period

or occurrence has been reached.

o Remittance Advice Remark Code (RARC) N362 - The number of Days or Units of

service exceeds our acceptable maximum.

o Group Code PR (Patient Responsibility) assigning financial liability 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.