Tuesday, December 20, 2011

Health Care Services Decision Reason Codes - All

Health Care Services Decision Reason Codes are used to indicate the primary reason for the certification action code assigned as part of a health care services review.


01 Price Authorization Expired Start: 01/10/2001

02 Price authorization no longer required Start: 01/10/2001

03 Product not on the price authorization Start: 01/10/2001

04 Authorized Quantity Exceeded Start: 01/10/2001

05 Special Cost Incorrect Start: 01/10/2001

06 No Credit Allowed Start: 01/10/2001

07 Administrative Cancellation Start: 01/10/2001

08 Unit resale higher than authorized Start: 01/10/2001

09 Out of Network Start: 01/10/2001

0A Testing not Included Start: 01/10/2001

0B Request Forwarded To and Decision Response Forthcoming From an External Review Organization Start: 01/10/2001

0C Authorization/Access Restrictions Start: 01/10/2001

0D Requires PCP authorization Start: 01/10/2001

0E Provider is Not Primary Care Physician Start: 01/10/2001

0F Not Medically Necessary Start: 01/10/2001

0G Level of Care Not Appropriate Start: 01/10/2001

0H Certification Not Required for this Service Start: 01/10/2001

0J Certification Responsibility of External Review Organization Start: 01/10/2001

0K Primary Care Service Start: 01/10/2001

0L Exceeds Plan Maximums Start: 01/10/2001

0M Non-covered Service Start: 01/10/2001

0N No Prior Approval Start: 01/10/2001

0P Requested Information Not Received Start: 01/10/2001

0Q Duplicate Request Start: 01/10/2001

0R Service Inconsistent with Diagnosis Start: 01/10/2001

0S Pre-existing Condition Start: 01/10/2001

0T Experimental Service or Procedure Start: 01/10/2001

0U Additional Patient Information required Start: 01/10/2001

0V Requires Medical Review Start: 01/10/2001

0W Disposition pending review Start: 01/10/2001

0X Service Inconsistent with Provider Type Start: 01/10/2001

0Y Service inconsistent with Patient's Age Start: 01/10/2001

0Z Service inconsistent with Patient's Gender Start: 01/10/2001

10 Product/service/procedure delivery pattern (e.g., units, days, visits, weeks, hours, months) Start: 01/10/2001

11 Pricing Start: 01/10/2001

12 Patient is restricted to specific provider Start: 01/10/2001

13 Service authorized for another provider Start: 01/10/2001

14 Plan/contractual guidelines not followed Start: 01/10/2001

15 Plan/contractual geographic restriction Start: 01/10/2001

16 Inappropriate facility type Start: 01/10/2001

17 Time limits not met Start: 02/01/2002

18 Notification received Start: 06/01/2002

19 Cosmetic Start: 06/01/2002

20 Once in a lifetime restriction applies Start: 02/01/2004

21 Transport Request Denied Start: 06/01/2004

22 Ambulance Certification Segment information doesn't correspond to Transport Address Segment Start: 06/01/2004

23 Mileage cannot be computed based on data submitted Start: 06/01/2004

24 Computed mileage is inconsistent with transport information or service units submitted Start: 06/01/2004

25 Services were not considered due to other errors in the request. Start: 06/06/2010

26 Missing Provider Role Start: 06/05/2011
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download