CMS Pub. 100-04, ch. 32, § 100.5

(RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages

(Rev. 11875; Issued:02-23-23; Effective: 09-26-22; Implementation: 03-24-23)

Contractors 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

cochlear implantation devices and services for beneficiaries with moderate-to-profound hearing loss in

patients with hearing test scores ≤ 40% through 9/25/22; ≤ 60% effective 9/26/22.

Use the following messages when denying services on claims:

• submitted on a TOB other than 11X, 12X (except surgical procedures), 13X or 85X (For Part A only);

or

• submitted without the Q0/Q1; or

• submitted without diagnostic code Z000.6 or

• submitted without one of the CPT/HCPCs listed (92521-92524, 92507, 92601- 92604, L7510, L8614,

L8619, 69930)

CARC 50 - “These are non-covered services because this is not deemed a ‘medical necessity’

by the payer”

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.”

MSN 15.20 = “The following policies were used when we made this decision:

NCD 50. 3”

Spanish translation: “Las siguientes políticas fueron utilizadas cuando se tomó esta

decisión: NCD 50.3”)

Contractors processing institutional claims shall use the following MSN message in addition to

MSN 15.20:

MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is covered.

An LCD was used for your claim. You can compare your case to the LCD, and send

information from your doctor if you think it could change our decision. Call 1-800-

MEDICARE (1-800-633-4227) for a copy of the LCD.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le

ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación.

Usted puede comparar su caso con la determinación y enviar información de su médico

si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al

1-800-MEDICARE (1-800-633-4227).

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that,

when used for the same line item, both messages will appear on the same MSN.

Group Code: CO (Contractual Obligation) assigning financial liability to the provider

A/B MACs (Part A) shall deny for any covered dx audiology/therapy services related to cochlear implantation

with the following messages:

Use the following messages when denying services on claims:

• Submitted on a TOB other than 11X, 12X (except surgical procedures), 13X or 85X (Part A only), or

• submitted without diagnostic code Z00.6

• submitted without one of the CPT/HCPCs listed (92521-92524, 92507, 92601- 92604, L7510, L8614,

L8619, 69930)

CARC 50 - “These are non-covered services because this is not deemed a ‘medical necessity’

by the payer”

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.”

MSN 15.20 = “The following policies were used when we made this decision:

NCD 50. 3”

Spanish translation: “Las siguientes políticas fueron utilizadas cuando se tomó esta

decisión: NCD 50.3”)

Contractors processing institutional claims shall use the following MSN message in addition to

MSN 15.20:

MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is covered.

An LCD was used for your claim. You can compare your case to the LCD, and send

information from your doctor if you think it could change our decision. Call 1-800-

MEDICARE (1-800-633-4227) for a copy of the LCD.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le

ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación.

Usted puede comparar su caso con la determinación y enviar información de su médico

si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al

1-800-MEDICARE (1-800-633-4227).

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that,

when used for the same line item, both messages will appear on the same MSN.

Group Code: CO (Contractual Obligation) assigning financial liability to the provider

A/B/MACs (Part B) shall deny claims for evaluation and therapeutic services related to cochlear implantation.

NOTE: Modifiers -Q0/-Q1 do not need to be applied to these services (92601– 92604, 92521-92524 or any

applicable audiology codes).

Use the following messages when denying services on claims:

• Submitted without one of the CPT/HCPCs listed (92521-92524, 92507, 92601- 92604).

CARC 50 - “These are non-covered services because this is not deemed a ‘medical necessity’

by the payer”

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.”

MSN 15.20 - “The following policies were used when we made this decision: NCD 50. 3”

Spanish translation: “Las siguientes políticas fueron utilizadas cuando se tomó esta

decisión: NCD 50.3”)

Group Code - CO (Contractual Obligation) assigning financial liability to the provider