Claim Change Reason Codes
The provider submits one of the following claim change reason codes to its A/B MAC (A)
with each debit-only or cancel-only adjustment request:
|
Bill Type
|
Reason Code
|
Explanation
|
|
XX7
|
D0 (zero)
|
Change
to service dates
|
|
XX7
|
D1
|
Change
in charges
|
|
XX7
|
D2
|
Change
in revenue codes/HCPCS
|
|
XX7
|
D3
|
Second
or subsequent interim PPS bill - inpatient only
|
|
XX7
|
D4
|
Change
in GROUPER input (diagnoses or procedures) - inpatient only
|
|
XX8
|
D5
|
Cancel-only
to correct a HICN or provider identification number
|
|
XX8
|
D6
|
Cancel-only
to repay a duplicate payment or OIG overpayment (includes cancellation of an
outpatient bill containing services required to be included on the inpatient
bill.)
|
|
XX7
|
D7
|
Change
to make Medicare the secondary payer
|
|
XX7
|
D8
|
Change
to make Medicare the primary payer
|
|
XX7
|
D9
|
Any
other change
|
|
XX7
|
E0 (zero)
|
Change
in patient status
|
The provider may not submit more than one claim change reason code per adjustment
request. It must choose the single reason that best describes the adjustment it is
requesting. It should use claim change reason code D1 only when the charges are the only
change on the claim. Other claim change reasons frequently change charges, but the
provider may not "add" reason code D1 when this occurs.
The claim change reason code is entered as a condition code on the ASC X12 837
institutional claim format or on the hard copy Form CMS-1450 For reason codes D0-D4
and D7-D9, submit a debit-only adjustment request, bill type XX7. For reason codes D5
and D6, submit a cancel-only adjustment request, bill type XX8.
Edits on Claim Change Reason Codes
The following edits are based on the claim change reason code. The A/B MAC (A) must
apply them to each incoming adjustment request.
• If the type of bill is equal to XX7 and the claim change reason code is not equal to
D0-D4, D7-D9, or E0, the A/B MAC (A) rejects the request back to the provider
with the following error message, "Claim change reason code must be present and
equal to D0-D4, D7-D9, or E0 for a debit-only adjustment request."
• If the type of bill is equal to XX8 and the claim change reason code is not equal to
D5-D6, the A/B MAC (A) rejects the request back to the provider with the
following error message, "Claim change reason code must be present and equal to
D5-D6 for a cancel-only adjustment request."
• If the type of bill is equal to XX7 or XX8 and the ICN/DCN of the claim being
adjusted is not present, the A/B MAC (A) rejects the request back to the provider
with the following message, "ICN/DCN of the claim being adjusted is required for
an adjustment request."
