Reason Code U5233 - JF Part A

Reason Code Narrative

FOR PPS CLAIMS, AND CLAIMS WITH PROVIDER NUMBERS BEGINNING WITH '210', THE ADMISSION DATE FALLS WITHIN A RISK GHO PAID PERIOD, BUT NO GHO PAID CODE OR CONDITION CODE '69', IS INDICATED ON THE CLAIM. OR FOR NON-PPS INPATIENT AND SNF CLAIMS, THE STATEMENT DATES FALL WITHIN, OR OVERLAP A RISK GHO PERIOD, BUT NO GHO PAID CODE OR CONDITION CODE '69' IS INDICATED ON THE CLAIM.

Common Reason Code Errors

• The claim admit date falls within a Medicare Advantage (MA) plan enrollment period.
• Claim is billed with condition codes for informational only billing; however, admit date does not fall within an MA plan period for the patient.

Common Reason Code Corrections

• Indirect Medical Education (IME) teaching facilities require condition code 04 and 69 when billing for informational only claims if admit date falls within a MA plan period.
• For all other informational only claims, condition code 04 is required for claim to process if admit date falls within an MA plan. No reimbursement is made on these claims.
• If patient is not enrolled in an MA plan at time of admit, condition codes 04 and/or 69 should be removed from claim.

Resources

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 20.3
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 90

View reason code list, return to Reason Code Guidance page.