CMS Pub. 100-04, ch. 32, § 180.3

This service may be paid as a primary treatment for patients with clinically localized prostate cancer, Stages

T1 – T3. The ultrasonic guidance associated with this procedure will not be paid for separately, but is bundled

into the payment for the surgical procedure. When one provider has furnished the cryosurgical ablation and

another the ultrasonic guidance, the provider of the ultrasonic guidance must seek compensation from the

provider of the cryosurgical ablation.

Effective July 1, 2001, cryosurgery performed as salvage therapy, will be paid only according to the coverage

requirements described above.

Type of facility and setting determines the basis of payment:

• For services performed on an inpatient or outpatient basis in a CAH, TOBs 11x and 85x: the FI will

pay 101 percent of reasonable cost minus any applicable deductible and coinsurance.

• For services performed on an inpatient basis in short term acute care hospitals, (including those in

Guam, America Samoa, Virgin Islands, Saipan, and Indian Health Services Hospitals) TOB 11x: the

FI will pay the DRG payment minus any applicable deductible and coinsurance.

• For services performed on an outpatient basis in hospitals subject to the Outpatient PPS, TOB 13x: the

FI will pay the assigned APC minus any applicable deductible and coinsurance.

• For outpatient services in hospitals that are exempt from OPPS (such as in American Samoa, Virgin

Islands, Guam, and Saipan) TOBs 13x: the FI will pay reasonable cost, minus any applicable

deductible and coinsurance.

• For outpatient services in Indian Health Service hospitals TOBs 13x and 83x: the FI will pay the ASC

payment amount for TOB 83x. minus any applicable deductible and coinsurance.

• For inpatient or outpatient services in hospitals in Maryland, make payment according to the State Cost

Containment system.

For services performed on an inpatient basis: the hospitals exempt from inpatient acute care PPS shall be paid

on reasonable cost basis, minus any applicable deductible and coinsurance.

180.4 - Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group

Codes, and Medicare Summary Notice Messages

(Rev 2544, Issued: 09-13-2012, Effective: 10-01-2012, Implementation: 10-01-2012)

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

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.

NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.

• 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.

NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.

• 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.

NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.

• 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.

NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.

• 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.

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.

NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.

• Denying claims for alcohol misuse counseling session HCPCS code G0443 when there is no claim in

history for the screening service HCPCS code G0442 in the prior 12 months:

° Medicare Summary Notice (MSN) 16.26 – Medicare does not pay for services or items related

to a procedure that has not been approved or billed.

° Claim Adjustment Reason Code (CARC) B15 – This service/procedure requires that a

qualifying service/procedure be received and covered. The qualifying other service/procedure

has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification

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

° Remittance Advice Remark Code (RARC) M16 – Alert: Please see our web site, mailings, or

bulletins for more details concerning this policy/procedure/decision.

° Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a

claim is received with a modifier indicating a signed ABN is on file.

° Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is

received without a modifier indicating no signed ABN is on file.

180.5 – Additional CWF and Contractor Requirements

(Rev 2544, Issued: 09-13-2012, Effective: 10-01-2012, Implementation: 10-01-2012)

• When applying frequency, CWF shall count 11 full months following the month of the last alcohol

misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.

• CWF shall reject incoming claims when G0443 PROF is billed if four G0443 services have been billed

and posted to the BEHV auxiliary file within the 12 month period.

• CWF shall continue to reject incoming claims with consistency error code ‘32#3’ when HCPCS code

G0442 PROF and HCPCS code G0443 PROF are billed on same day for TOB 71X, 77X, 85X with

096X, 097X and 098X.

• Contractors and CWF shall use the last date of G0442 PROF for counting the 12-month period for

G0443 PROF services.

° Contractors and CWF shall apply all the same TOBs (13x,71x, 77x and 85x with Rev. Code 96, 97

and 98) POS (11, 22, 49 and 71), no deductible/co-insurance and institutional/professional

processing for G0443 that was implemented for G0442 in CR 7633.

• If a claim with G0442 is cancelled, CWF shall do a look back for claims with G0443 and create an

IUR (Information Unsolicited Response) along with a Trailer ‘24’ back to the contractor to reject the

G0443 claim(s) paid within the 12 month period of the G0442 claims.

• CWF shall display the number of counseling sessions remaining for G0443 PROF on all CWF

provider query screens (HUQA, HIQA, HIQH, ELGA, ELGB, ELGH).

• CWF shall display the remaining PROF services counting DOWN from four (4) for the HCPCS code

‘G0443’ on the MBD/NGD extract file.

° CWF shall calculate a next eligible date for G0442 PROF and G0443 PROF for a given

beneficiary.

° The calculation shall include all applicable factors including beneficiary Part B entitlement

status, beneficiary claims history and utilization rules.

° When there is no next eligible date, the CWF provider query screens shall display an 8-position

alpha code in the date field to indicate why there is not a next eligible date.

° Any change to beneficiary master data or claims data that would result in a change to any next

eligible date shall result in an update to the beneficiary’s next eligible date.

NOTE: If G0442 is not paid, the beneficiary is not eligible for G0443.

ο CWF shall create a utility to remove previously posted G0442 TECH for the AUX file.

ο CWF shall remove G0442/G0443 TECH from editing, MBD, NGD, Provider Inquiry screens

and all other applicable areas (i.e., HICR) previously done under CR 7633.

Frequency Requirements

When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse

screening visit, G0442, before allowing subsequent payment of another G0442 screening. Additionally, CWF

shall create an edit to allow alcohol misuse brief behavioral counseling, HCPCS G0443, no more than 4 times

in a 12-month period. CWF shall also count four alcohol misuse counseling sessions HCPCS G0443 in the

same 12-month period used for G0442 counting from the date the G0442 screening session was billed.

When applying frequency limitations to G0442 screening on the same date of service as G0443 counseling,

CWF shall allow both a claim for the professional service and a claim for a facility fee. CWF shall identify

the following institutional claims as facility fee claims for screening services: TOB 13X, TOB 85X when the

revenue code is not 096X, 097X, or 098X. CWF shall identify all other claims as professional service claims

for screening services (professional claims, and institutional claims with TOB 71X, 77X, and 85X when the

revenue code is 096X, 097X, or 098X). NOTE: This does not apply to RHCs and FQHCs.