CMS Pub. 100-04, ch. 32, § 80.8

Edit 1 - Should CWF receive a claim from an FI for G0245 or G0246 and a second claim from a contractor for

either G0245 or G0246 (or vice versa) and they are different dates of service and less than 6 months apart, the

second claim will reject. CWF will edit to allow G0245 or G0246 to be paid no more than every 6 months for

a particular beneficiary, regardless of who furnished the service. If G0245 has been paid, regardless of

whether it was posted as a facility or professional claim, it must be 6 months before G0245 can be paid again

or G0246 can be paid. If G0246 has been paid, regardless of whether it was posted as a facility or

professional claim, it must be 6 months before G0246 can be paid again or G0245 can be paid. CWF will not

impose limits on how many times each code can be paid for a beneficiary as long as there has been 6 months

between each service.

The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the

CWF documentation. Based on the CWF reject code, the contractors and FIs must deny the claims and return

the following messages:

MSN 18.4 -- This service is being denied because it has not been __ months since your last examination

of this kind (NOTE: Insert 6 as the appropriate number of months.)

RA claim adjustment reason code 96 – Non-covered charges, along with remark code M86 – Service denied

because payment already made for same/similar procedure within set time frame.

Edit 2

The CWF will edit to allow G0247 to pay only if either G0245 or G0246 has been submitted and accepted as

payable on the same date of service. CWF will return a specific reject code for this edit to the contractors and

FIs that will be identified in the CWF documentation. Based on this reject code, contractors and FIs will deny

the claims and return the following messages:

MSN 21.21 - This service was denied because Medicare only covers this service under certain

circumstances.

RA claim adjustment reason code 107 – The related or qualifying claim/service was not identified on this

claim.

Edit 3

Once a beneficiary’s condition has progressed to the point where routine foot care becomes a covered service,

payment will no longer be made for LOPS evaluation and management services. Those services would be

considered to be included in the regular exams and treatments afforded to the beneficiary on a routine basis.

The physician or provider must then just bill the routine foot care codes, per Pub 100-02, Chapter 15, §290.

The CWF will edit to reject LOPS codes G0245, G0246, and/or G0247 when on the beneficiary’s record it

shows that one of the following routine foot care codes were billed and paid within the prior 6 months: 11055,

11056, 11057, 11719, 11720, and/or 11721.

The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the

CWF documentation. Based on the CWF reject code, the contractors and FIs must deny the claims and return

the following messages:

MSN 21.21 - This service was denied because Medicare only covers this service under certain

circumstances.

The RA claim adjustment reason code 96 – Non-covered charges, along with remark code M86 – Service

denied because payment already made for same/similar procedure within set time frame.