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CGS Administrators, LLC

Serving the states of MN, WI, IL, IN, OH, KY and MI

August 31, 2016

Information Required on Claims for Miscellaneous Healthcare Common Procedure Coding System (HCPCS) Codes

Joint DME MAC Publication

Common Electronic Data Interchange Edits

Any HCPCS code with a narrative description that indicates miscellaneous, not otherwise classified (NOC), unlisted, or non-specified that is billed to the DME MAC electronically must include in the SV101-7 segment for HIPAA 5010A1 claims, a concise description of the NOC code. This segment is limited to 80 characters. If the claim is submitted without this information it will not pass the front-end edits and will be rejected by CEDI with:

Additional Information Required for Adjudication by the DME MAC
In addition, items billed with any HCPCS code with a narrative description that indicates miscellaneous, NOC, unlisted, or non-specified, that is billed to the DME MAC must also include the following in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or in Item 19 of the paper claim form:

Miscellaneous HCPCS codes billed without this information will be denied for missing incomplete, invalid information and will need to be resubmitted with the missing information.

Suppliers billing miscellaneous-coded products are reminded that items that have a specific HCPCS code must not be billed with miscellaneous HCPCS codes.& Inappropriate billing of miscellaneous HCPCS codes can result in a claim return/reject or denial of the HCPCS code for invalid coding.

Questions concerning HCPCS code classifications should be directed to the Pricing, Data Analysis and Coding (PDAC) contractor - Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www.dmepdac.com/External Website

Refer to the applicable Local Coverage Determinations (LCDs) and related Policy Articles for additional information on requirements for miscellaneous HCPCS codes.

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