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February 23, 2012 - Revised: 07.03.19

Appeals, Adjustments and the D9 Claim Change Reason (Condition) Code

This article explains:

  • The difference between requesting an Appeal (Redetermination) and submitting adjustment claims
  • When to use the the automated Clerical Error Reopening (CER) Request process and First request: Redetermination Form

When to use the D9 condition code (also known as the claim change reason code for 'Any Other Change')

When to Appeal

You may appeal a claim or claim line that receives a full or partial medical denial. If a claim or line item is medically denied (status location = D B9997) and you have medical evidence that the service should be covered by Medicare, you may submit an appeal through the myCGS web portal (for registered users) or by using the First Request: Redetermination Request FormPDF.

When to Adjust

Claims that are processed, paid, or rejected (status location code = P B9997 or R B9997) and are 'posted' to Medicare history in the Common Working File (CWF) can be adjusted. If a historical record of a claim exists in CWF, an adjustment transaction must be processed to update the historical record. These adjustments may be made through Direct Data Entry (DDE) or through a vendor's software. It is important to note if the claim was partially denied, (i.e., the claim contains a medically denied line), you may make adjustments electronically to line items that were not medically denied. Please refer to the instructions below, "Reminder About Adjustments on Claims with Medically Denied Lines".

When to Submit an Online Adjustment

Submit an online adjustment using bill type XX7 to correct:

  • Number of inpatient days
  • Claims coding
  • Adding additional charges
  • Blood deductible
  • Servicing hospital
  • Inpatient cash deductible of more than $1
  • Diagnosis Related Group (DRG) code *
  • Discharge status in a Prospective Payment System (PPS) hospital
  • Outlier payment amount

*If an adjustment the hospital initiates results in a change to a higher weighted DRG, CGS edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted. If it is, CGS will process the claim for payment. If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, CGS will process the claim for payment and forward it to CWF.

Reminder About Adjustments on Claims with Medically Denied Lines

If a line item on a claim is medically denied (status location = D B9997) and you have medical evidence that to the service should be covered by Medicare, file an appeal through the myCGS portal or by submitting a Redetermination Request FormPDF.

If there is a medically denied line item on the claim, but you need to adjust the claim to make a change to something other than the denied line item, key the adjustment in the system with the appropriate condition code(s) that describes the change(s) on the claim. Once adjusted, the claim will go to an S 'suspense' status and location to be reviewed.

When to Submit a Clerical Error Reopening (CER)

The Centers for Medicare & Medicaid Services (CMS) defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor, such as:

  • Mathematical or computational mistakes
  • Transposed procedure or diagnostic codes
  • Inaccurate data entry
  • Misapplication of a fee schedule
  • Computer errors
  • Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate
  • Incorrect data items, such as provider number, use of a modifier or date of service

If there is a medically denied line item on the claim, the Fiscal Intermediary Shared System (FISS) may not allow you to complete the adjustment electronically.

Beginning January 1, 2016, CMS implemented the automated Clerical Error Reopening (CER) process, which allows providers to perform reopenings electronically.

CGS encourages providers to use the CER process. Instructions for the process are communicated in articles:

If providers are unable to use the automated CER process, submit a hard copy adjustment using the Clerical Error Reopening Request FormPDF.

Note: Clerical errors or minor errors are limited to errors in form and content, which does not include failure to bill for certain items or services. CGS will not add items or services, based on a reopening request, that were not previously billed, with the exception of a few limited items that cannot be filed on a claim alone (e.g., HCPCS codes G0369, G0370, G0371 and G0374). Third party payer errors are not considered clerical errors.

When to Use the D9 Claim Change Reason (Condition) Code

The following chart provides information on claim change reason condition codes. Only one claim change reason code can be used on each claim being adjusted. If more than one claim change reason code is entered, FISS will reject the claim.

Code Description Code Description
D0 Changes to Service Dates D6 Cancel only to repay a duplicate OIG payment
D1 Changes to Charges D7** Change to Make Medicare Secondary Payer
D2 Changes in Revenue Codes/HCPCS/HIPPS D8 Change to Make Medicare Primary Payer
D3 Second or Subsequent Interim PPS Bill D4 Changes in Grouper Codes
D5 Cancel to correct HICN or Provider ID D9*** Any Other Change
E0 (zero) Change in patient Status    

** Use D9 when adjusting primary payer to bill for conditional payment.

***This code is used if adding a modifier to change liability and there is no change to the covered charge amount. D9 Condition Code

Use the D9 claim change reason code on an adjustment claim to reflect any other changes to be made to a claim that was already processed:

  • Adjustment to a claim when an original claim was rejected for Medicare Secondary Payer (MSP) but Medicare is primary.
  • When the original claim was processed as an MSP or conditional claim and a change needs to be made to the claim such as a change in the MSP value code amount
  • When you are making multiple changes to a claim (add remarks specifying "multiple changes" and indicate the changes)

If an adjusted claim is in a Return to Provider (RTP) status (T B9997), it is important to verify that the D9 code is being used correctly. If the D9 is the best code to use, the claim will need to include remarks indicating the reason for the adjustment. If remarks are not submitted on the claim, then the Medicare contractor will return the claim back to the provider using reason code 37541.

Note:

  • If the adjusted claim is in a Return to Provider (RTP) status (T B9997), verify that the D9 code is being used correctly. If you determine that D9 is the best code to use, include remarks on the claim indicating the reason for the adjustment. If remarks are not submitted on the claim, then CGS will return the claim back to the provider using reason code 37541.
  • CGS suspends all adjustment requests with claim change reason codes D4, D8 and D9 for investigation and research.

References:

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