CMS Pub. 100-04, ch. 18, § 60.8

All messages refer to ANSI X12N 835 coding.

A. If the claim for a screening FOBT, a screening flexible sigmoidoscopy, or a screening

barium enema is being denied because the patient is less than 45 years of age, use:

Claim Adjustment Reason Code (CARC) 6 “The procedure/revenue code is inconsistent with

the patient’s age,” at the line level; and, Remittance Advice Remark Code (RARC) N129

“Not eligible due to patient’s age”

B. If the claim for a screening FOBT, a screening colonoscopy, a screening flexible

sigmoidoscopy, or a screening barium enema is being denied because the time period between

the test/procedure has not passed, use:

• CARC 119 “Benefit maximum for this time period or occurrence has been reached” at the

line level.

C. If the claim is being denied for a screening colonoscopy (HCPCS G0105) or a screening

barium enema (HCPCS G0120) because the patient is not at a high risk, use:

• CARC 46 “This (these) service(s) is (are) not covered” at the line level; and,

• RARC M83 “Service is not covered unless the patient is classified as a high risk.” at the line

level.

D. If the service is being denied because payment has already been made for a similar

procedure within the set time frame, use:

• CARC 18, “Duplicate claim/service” at the line level; and,

• RARC M86 “Service is denied because payment already made for similar procedure within a

set timeframe.” at the line level.

E. If the claim is being denied for a non-covered screening procedure such as HCPCS G0122,

use:

CARC 49, “These are non-covered services because this is a routine exam or screening

procedure done in conjunction with a routine exam.”

F. If the claim is being denied because the code is invalid, use the following at the line level:

• CARC B18 “Payment denied because this procedure code/modifier was invalid on the date

of service or claim submission.”

G. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) when furnished more than once in a 3-year

period [at least 2 years and 11 full months (35 months total) must elapse from the date of the last

screening], use:

• 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 CO assigning financial liability to the provider, if a claim is received with a GZ

modifier indicating no signed ABN is on file.

H. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) when beneficiary is not between the ages 45-85,

use:

• 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 CO assigning financial liability to the provider, if a claim is received with a GZ

modifier indicating no signed ABN is on file.

I. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) when the claim does not contain ICD-10

diagnosis codes Z12.12 OR Z12.11), use:

• 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, if a claim is received with a GZ

modifier indicating no signed ABN is on file.

J. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 - Effective January 1,

2016, HCPCS G0464 has been discontinued and replaced with CPT 81528) or Blood-based Biomarker test

(HCPCS G0327) when claims are submitted on a TOB other than 13X, 14X, or 85X, use:

• CARC 170: “Payment is denied when performed/billed by this type of provider. Note: Refer to the 835

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

• RARC N95 – “This provider type/provider specialty may not bill this service.”

Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no

signed ABN is on file.