CMS Pub. 100-04, ch. 18, § 30.9

Pap Smear Screening: If high risk factors are not present, and the screening Pap smear and/or

screening pelvic examination is being denied because the procedure/examination is performed

more frequently than allowed, use existing ANSI X12N 835:

• Claim adjustment reason code 119 - “Benefit maximum for this time period has been

reached” at the line level, and

• Remark code M83 - “Service is not covered unless the patient is classified as at high risk”

at the line item level.

HPV Screening: Effective for claims with dates of service on and after July 9, 2015:

A. If denying line-items on claims containing HCPCS G0476, HPV screening, when reported

more than once in a 5-year period [at least 4 years and 11 months (59 months total) must elapse

from the date of the last screening], use the following messages:

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD

provides a coverage determination as to whether a particular item or service is covered. A copy of

this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may

contact the contractor to request a copy of the NCD.”

Group Code PR (Patient Responsibility) assigning financial responsibility 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).

B. If denying line-items on claims containing HCPCS G0476, HPV screening, when the

beneficiary is not between the ages of 30-65, use the following messages:

CARC 6: “The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the

835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.”

RARC N129: “Not eligible due to the patient’s age.”

Group Code PR (Patient Responsibility) assigning financial responsibility 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).

C. If denying line items on claims containing HCPCS G0476, HPV screening, when the claim

does not contain the appropriate ICD-10 diagnosis codes listed below:

ICD-10: Z11.51 and Z01.411, or, Z01.419

Use the following messages:

CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare

Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD

provides a coverage determination as to whether a particular item or service is covered. A copy of

this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may

contact the contractor to request a copy of the NCD.”

Group Code CO assigning financial liability to the provider