CMS Pub. 100-04, ch. 32, § 410.4

Effective for claims with DOS on or after January 21, 2020, contractors shall reject/deny claims that do not contain the

appropriate diagnosis/procedure coding noted in section 410.2 and use these messages:

Claim Adjustment Reason Code (CARC) 50 - These are non-covered services because this is not deemed a 'medical

necessity' by the payer.

Remittance Advice Remark Code (RARC) M64 – Missing/incomplete/invalid other diagnosis.

Group Code CO (Contractual Obligations) or PR (Patient Responsibility) dependent on liability.

MSN 15.20 - “The following polices were used when we made this decision: NCD 30.3.3.”

Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 30.3.3.”

NOTE: Due to system requirement, the Fiscal Intermediary Shared System (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.

In addition to the codes noted in section 410.2, contractors shall afford appeal rights to all denied parties.

Contractors shall return to provider/return as unprocessable claims for acupuncture for cLBP for services 13 through 20

per annum without the -KX modifier and use these messages:

CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Note:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC N657 - This should be billed with the appropriate code for these services.

Group Code CO

Contractors shall reject/deny more than 20 claims per annum for acupuncture for cLBP and use the following messages:

CARC 96 - Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the

NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835

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

RARC N640 - Exceeds number/frequency approved/allowed within time period.

Group Code - CO (Contractual Obligation)

MSN 15.20 - “The following polices were used when we made this decision: NCD 30.3.3.”

Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 30.3.3.”

MSN 15.19: “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy

of the LCD at www.cms.gov/medicare-coverage-database (use the MSN Billing Code for the CPT/HCPCS Code) and

send with information from your doctor."

Spanish Version - Usamos una Determinación de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para

apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN

para el código "CPT/HCPCS") y envíela con la información de su médico.

NOTE: Due to system requirements, the Fiscal Intermediary Shared System 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.