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Payment Remarks Codes - Work Area

Page history last edited by PBworks 6 years, 10 months ago

This page lists the Payment Remark Codes for the 835 that are desirable/needed for Workers' Compensation.

These codes have NOT been approved yet and therefore cannot be used on the 835.

As the codes are approved they will be indicated on this page and published on the Education and Outreach section.

 

WC Payment Remark Codes
# Proposed description Notes
1 Documentation of unlisted or “by report” BR code was not received. Please resubmit your bill with the appropriate supporting documentation.  
2 Documentation of unlisted or "by report" BR code was not sufficiently documented in the attachments submitted. We are unable to make a payment without supplementary documentation giving a clearer description of the service. Please resubmit your bills with additional supporting documentation.  
3 The documentation does not support the level of service billed. Reimbursement was made for a code that is supported by the description of the service in documentation submitted with the billing.  
4 Reimbursement denied as this service requires prior authorization and none was identified.  
5 The charge for both the technical and professional component of this service have already been paid to another provider.  
6 Documentation indicating the amount of time or begin/end time for this service is required. Documentation was not submitted or did not include the time information.  
7 Missing/incomplete/insufficient requested documentation  
8 Reimbursement for physical therapy assessment or evaluation codes are denied. Provider is not eligible for reimbursement.  
9 Documentation supporting reimbursement for both test and measurements and evaluation and management or assessment and evaluation on the same day is required in accordance with jurisdictional guidelines  
10 Charge exceeds the maximum number of physical therapy modalities in a single visit. Reimbursement is made in accordance with the applicable fee schedule.  
11 Reimbursement denied for physical medicine extended time service. Charges billed without the "initial 30 minutes" base code.  
12 Charges for assessment and evaluation charge is denied. Services are reimbursable once within a 30 day period. The provider has billed for a physical therapy evaluation within the last 30 days.  
13 Reimbursement for physical medicine procedures, including Chiropractic Manipulation and acupuncture codes are denied. Charges exceed the maximum time allowed per visit without prior authorization.  
14 Reimbursement for physical medicine procedures, including Chiropractic Manipulation and Acupuncture codes are denied. Charges exceed the maximum number of modalities allowed per visit without prior authorization.  
15 Reimbursement denied based on jurisdictional guidelines regarding multiple services (cascade).  
16 Reimbursement based on jurisdictional guidelines regarding multiple services (cascade).  
17 Reimbursement for evaluation and management service in addition to physical medicine/acupuncture service provided during the same visit is made in accordance with the applicable fee schedule.  
18 Reimbursement denied. Documentation not submitted or does not support follow-up evaluation and management visit and physical medicine treatment in the same visit.  
19 Reimbursement denied. Provider is not eligible for reimbursement of evaluation and management services.  
20 Reimbursement of the initial casting service is included within the value of a fracture or dislocation reduction service.  
21 Reimbursement is denied. The visit or service billed, occurred within the global surgical period and is not separately reimbursable.  
22 Reimbursement for additional arthroscopic services were reduced in accordance with the applicable surgery guidelines.  
23 Reimbursement for the initial evaluation and management charge was reduced. Reimbursement is made using code 99025 in accordance with surgical guidelines.  
24 Reimbursement for assistant surgeon services are reduced in accordance with surgical guidelines  
25 Reimbursement for surgical assistant services are reduced in accordance with surgical guidelines.  
26 Reimbursement for assistant surgeon services are denied as not normally warranted for this procedure according to surgical guidelines  
27 Reimbursement for multiple surgeon services is not warranted for this procedure according to surgical guidelines. Please provide documentation that supports the need for multiple surgeons.  
28 Reimbursement for service is denied. Administration of local anesthetic is included in the surgical service in accordance with surgical guidelines.  
29 Reimbursement for anesthesia is reduced . Modifier -47 was used to indicate regional anesthesia administered by the surgeon. Time units are not reimbursed in accordance with surgery guidelines.  
30 Patient’s physical status/condition not identified. Please provide documentation using ASA Physical Status indicators.  
31 Reimbursement for evaluation and management service is denied. Documentation does not support a separate significant, identifiable service performed with other services provided on the same day.  
32 Reimbursement for services denied. The billed service does not meet the requirements of a consultation  
33 Reimbursement for services denied. Documentation provided does not support prolonged evaluation and management service.  
34 Reimbursement reduced. Reimbursement is based on a generic equivalent as “No Substitution” documentation was not provided.  
35 Reimbursement for dispensing fee is denied. Dispensing fee is not applicable for over-the-counter medication or medication administered at the time of a visit.  
36 Reimbursement for this item was based on the documented actual cost.  
37 Reimbursement for progress report charges are denied. Charges are reimbursable to the primary treating physician or his/her designee.  
38 The Permanent and Stationary Report charge was disallowed as you are not the Primary Treating Physician or his/her designee.  
39 Reimbursement for additional documentation is denied as duplicate documentation was not requested  
40 No payment is being made for missed appointment, as none is necessarily owed  
41 No reimbursement is being made as this procedure is not usually performed in an outpatient surgical facility. Prior authorization is required but was not submitted.  
42 Service not paid under outpatient facility fee schedule.  
43 This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation. The bill will be reimbursed using the regular reimbursement methodology.  
44 Missing Admission Summary  
45 Missing Prescription Order  
46 Missing Physician Order  
47 Missing Diagnostic Report  
48 Missing Discharge Summary  
49 Missing Nursing Notes  
50 Missing Support Data for Claim  
51 Missing Physical Therapy Notes  
52 Missing Report of Tests and Analysis Report  
53 Missing Doctor First Report of Injury  
54 Missing Supplemental Medical Report  
55 Missing Medical Permanent Impairment  
56 Missing Medical Legal Report  
57 Missing Vocational Report  
58 Missing Work Status Report  
59 Missing Consultation Report  
60 Missing Permanent Disability Report  
61 Missing Itemized Statement  
62 Medical necessity denial. You may submit a request for an appeal/reconsideration.  
63 Appeal/reconsideration denied based on medical necessity.  
64 Reimbursement is denied as there is a visit limitation on Physical Therapy, Chiropractic and Occupational Therapy encounters without prior authorization for additional visits. If you object contact the Utilization Review unit."  
65 According to the Fee Schedule this service has a relative value of zero and therefore no payment is due.  
66 Payment is denied as the service was provided outside the designated Network.  
67 The applicable fee schedule does not contain the billed code. An allowance has been made based on a comparable service.  
68 The applicable fee schedule does not contain the billed code. No payment is being made at this time. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required.  
 

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