How the Eleventh Reason Code Gets Skipped
A transmittal CMS issued Wednesday says the Fiscal Intermediary Shared System has only ever handed the first ten medical policy reason codes on a Part A claim to the system that adjudicates them, and bypasses the rest. CMS concedes in writing that this lets some claims pay incorrectly. The fix was booked for the October release and just moved to January.
If you have ever cleared every reason code on a Part A denial, rebilled, and had the claim come back carrying an edit that was nowhere on the first remittance, CMS put the mechanism in writing on Wednesday.
Transmittal 13933, Change Request 14454, one page of summary and three business requirements. The third sentence is the one that matters.
"The current design allows for some claims/services to be paid incorrectly."
The design in question is the handoff between the Fiscal Intermediary Shared System and the Expert Claims Processing System, and the number that governs it is ten (chart below).
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