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Review Reason Codes and Statements

 

CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization requested) only for services that meet all Medicare rules. If the review results in a denied/non-affirmed decision, the review contractor provides a detailed denial/non-affirmed reason to the provider/supplier.

Historically, Medicare review contractors (Medicare Administrative Contractors, Recovery Audit Contractors and the Supplemental Medical Review Contractor) developed and maintained individual lists of denial reason codes and statements. If you deal with multiple CMS contractors, understanding the many denial codes and statements can be hard. In 2015 CMS began to standardize the reason codes and statements for certain services. As a result, providers experience more continuity and claim denials are easier to understand.

IRF CODE UPDATE:

The Inpatient Rehabilitation Facilities (IRF) Reason Codes and Statements originally released on September 9, 2017 have undergone some minor updates which include the addition of related policy citations and updates of reason statements in the Medical Necessity and Administrative categories.  This lasted version is dated December 8, 2017.

 

We developed review reason codes and statements for:

We are working on review reason codes and statements for:

    • Home Oxygen Therapy
    • Home Blood Glucose Monitoring Supplies
    • Chiropractic Services
    • Continuous Positive Airway Pressure (CPAP) Devices
    • Nebulizers
    • Infusion Pumps
    • Vitamin/Metabolic Tests

 

Please email PCG-ReviewStatements@cms.hhs.gov for suggesting a topic to be considered as our next set of standardized review result codes and statements.