Reason Code Narrative

LINE LEVEL REASON CODE TO INDICATE THAT NONE OF THE DIAGNOSES ON THE CLAIM SUPPORT THE MEDICAL NECESSITY OF THE SERVICE, AND NO DOCUMENTATION TO SUPPORT MEDICAL NECESSITY WAS PROVIDED. DENY THE SERVICE. THE PROVIDER IS LIABLE.

REASON CODE LOGIC UPDATED TO INCLUDE DIAGNOSIS CODES PRESENT IN THE “PRV” FIELDS ON CLAIM PAGE 5. THIS REASON CODE WILL NOT ASSIGN FOR TOB 12X, 13X, 14X, AND 76X WHEN A SERVICE LINE IS PACKAGED (IOCE STATUS INDICATOR FLAG 1 EQUALS N AND PAYMENT INDICATOR FLAG 2 EQUALS 9 ON CLAIM PAGE 31) FOR CLAIMS RECEIVED ON OR AFTER 07/01/19.

Common Reason Code Errors

• Line Level Reason Code to indicate that none of the diagnoses on the claim support the medical necessity of the service, and no documentation to support medical necessity was provided. Deny the service. The provider is liable.
• Provider has the option to submit a valid ABN
• Reason Code logic updated to include diagnosis codes present in the “PRV” Fields on claim page 5. This Reason Code will not assign for TOB 12x, 13x, 14x, and 76x when a service line is packaged (IOCE Status Indicator Flag 1 equals N and Payment Indicator Flag 2 equals 9 on claim page 31) for claims received on or after 07/01/19.

Common Reason Code Corrections

• Use appropriate diagnosis
• Check the applicable NCD to determine appropriate covered indications/ Bill with covered diagnosis per policy
• Submit documentation supporting billed diagnosis code, that service was medically necessary per coverage guidelines, etc.

Resources

• National Coverage Determination (NCD)
• CMS Internet Only Manual (IOM), Publication 100-03, Medicare National Coverage Determinations (NCD) Manual

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