DDE Reason Codes Inquiry Screen
The Reason Codes Inquiry screen provides information about individual reason codes, including a description of the code, status/location to be set on a claim, and what corrections may be performed to resubmit a claim. To view a summary of the most frequently requested reason codes, you may visit the Palmetto GBA Reason Code Help Tool on any of these pages:
Start the Inquiry Process
Take the following steps:
- From the main menu of the DDE system, navigate to the Inquiries menu by typing “01” and pressing enter.
- Next, enter “17” to access the Reason Codes Inquiry page.
- To view the narrative for a particular code, enter the five-digit reason code and press enter.
- To make additional inquiries, type over the reason code with the next code and press enter.
The fields on the Reason Codes Inquiry screen will be filled out with information about the code following the example shown:
| Field Name | Description |
|---|---|
| MNT | The last date the reason code was updated. |
| PLAN IND | Plan Indicator. All FISS shared maintenance customers will be “1”; the value for FISS shared processing customers will be determined at a later date. |
| REAS CODE | Identifies a specific condition detected during the processing of a record. |
| NARR TYPE | The type of reason code narrative provided. Defaults to “E” for external message. |
| EFF DATE | The effective date for the reason code or condition. |
| MSN REAS | Used when Medicare Summary Notices requiring BDL messages are produced. Will point to a specific MSN message on the ACS/MSN file. |
| EFF DATE | Effective date for the MSN reason code. |
| TERM DATE | Termination date for the MSN reason code. |
| EMC ST/LOC | Identifies the status and location to be set on an automated claim when it encounters the condition for a particular reason code. If it is the same for both hard copy and EMC claims, the data will only appear in the hard copy category and the system will default to the hard copy claims for action on EMC claims. |
| HC/PRO ST/LOC | Status and location code for hard copy and peer review organization claims. |
| PP LOC | The five-position alphanumeric post pay location of “B75XX.” |
| CC IND | The clean claim indicator instructs the system whether to pay interest or not if applicable. |
| TPTP A |
Tape-to-tape flag indicator for Part A, which controls the flow of the claim to CWF, to the provider via the remittance advice, to the PS&R system and for counting the claim for workload purposes. |
| B | Tape-to-tape Flag indicator for Part B. |
| NPCD A | The non-pay code for Part A, which identifies the reason for Medicare’s decision not to make payment. |
| B | The non-pay code for Part B. |
| HD CPY A | Instructs the system to generate a specific hardcopy document during the claim process on a Part A claim. |
| B | Instructs the system to generate a specific hardcopy document during the claim process on a Part B claim. |
| NB ADR | Identifies the number of times an Additional Documentation Request form is to be generated. Identified by a “1” or a “2.” |
| CAL DY | Identifies the number of calendar days a claim is to orbit after the generation of an ADR. |
| C/L | Identifies if the reason code has been depicted as applying to the claim or line. |
| NARRATIVE | Displays the description for the reason code. |
From the Reason Codes Inquiry screen, the ANSI equivalent screen can be accessed by pressing [F8]. To return to the Reason Codes Inquiry screen, press [F7].
The fields on the ANSI Related Reason Codes Inquiry screen will be filled out with information about the code following the example shown:
| Field Name | Description |
|---|---|
| REASON CODE | Displays the reason code entered on MAP1881. |
| MNT | The last date the reason code was updated. |
| PIMR ACTIVITY CODE |
The Program Integrity Management Reporting Activity Code for which the reason code is being categorized. AI = Automated CCI Edit AL = Automated Locally Developed Edit AN = Automated National Edit CP = Prepay Complex Probe Review DB = TPL or Demand Bill Claim Review MR = Manual Routine Review PS = Prepay Complex Provider-Specific Review RO = Reopening SS = Prepay Complex Service-Specific Review |
| DENIAL CODE |
The PIMR Denial reason code that is being categorized. NOPIMR = Default 100001 = Documentation Does Not Support Service 100002 = Investigation/Experimental 100003 = Item/Services Excluded from Medicare Coverage 100004 = Requested Information Not Received 100005 = Services Not Billed Under the Appropriate Revenue or Procedure Code (Include Denials Due to Unbundling in this Category). 100006 = Services Not Documented in Record 100007 = Services Not Medically Reasonable and Necessary 100008 = Skilled Nursing Facility Demand Bills 100009 = Daily Nursing Visits Are Not Intermittent/ Part Time 100010 = Specific Visits Did Not Include Personal Care Service 100011= Home Health Demand Bills 100012 = Ability to Leave Home Unrestricted 100013 = Physician's Order Not Timely 100014 = Service Not Ordered/Not Included in Treatment Plan 100015 = Services Not Included in Plan of Care 100016 = No Physician Certification (E.G. Home Health) 100017 = Incomplete Physician Order 100018 = No Individual Treatment Plan 100019 = Other |
| MR INDICATOR |
Medical Review Indicator: identifies whether or not the service received complex manual medical review. = The services did not receive manual medical review (default value). Y = Medical records received. This service received complex manual medical review. N = Medical records were not received. This service received routine manual medical review. |
| PCA INDICATOR |
Progressive Correction Action Indicator. = The Medical Policy Parameter is not PCA-related and is not included in the PCA transfer files. Y = The Medical Policy Parameter is PCA-related and is included in the PCA transfer files. N = The Medical Policy Parameter is not PCA-related and is not included in the PCA transfer files. |
| LMRP/NCD ID | Local Medical Review Policy and/or National Coverage Determination Identification numbers, which are assigned to the FMR reason code for reporting on the beneficiaries Medicare Summary Notice. |
ANSI Codes |
|
| ADJ REASONS | The ANSI Adjustment Reason Code related to the FISS reason code. |
| GROUPS |
The group code associated with the ANSI reason code. CO = Contractual Obligation CR = Correction and Reversals OA = Other Adjustment PR = Patient Responsibility |
| REMARKS | Describes the reason for non-payment. |
| APPEALS (A) | Inpatient only ANSI Appeals-A Code. |
| APPEALS (B) | Outpatient only ANSI Appeals-B Code. |
Category |
|
| EMC | Electronic Media Claim Category code of the claim that is returned on a 277 claim response. |
| HC | Hard Copy Claim Category code of the claim that is returned on a 277 claim response. |
STATUS |
|
| EMC | Electronic Media Claim Status code of the claim that is returned on a 277 claim response. |
| HC | Hard Copy Claim Status code of the claim that is returned on a 277 claim response. |
For more information about the DDE inquiries menu, refer to Section 3 of the DDE User’s Guide (PDF). Information about the Reason Codes Inquiry screen can be found under Section 3.H on page 52 of the guide.