Dealing with errors from Medicare can be intimidating, especially when there are so many reasons why a claim could be rejected. We know you're busy so instead of having to call Medicare or Genie Support each time your claim lands in Exceptions to Review, we have compiled a list of common Medicare Reason Codes and how to solve them.
This article focuses on the errors that appear in the Exceptions to Review window of File > Maintenance & Reports > Daily > Bulk Bill/DVA Transmission. They appear when there are issues in the claim as per the below image.
Before you begin
Please note that Genie populates the exception problem and reason based on the information supplied directly from Medicare. If you are ever unsure about why an exception may have been sent from Medicare you should contact them directly for clarification.
If you commonly come across exceptions that aren't in the table below, please comment in the Comments section below or contact our Support Team.
If you are feeling a bit overwhelmed with the Medicare online transmission system in Genie, you may benefit from one of our Training Courses or some one on one time with our Trainers.
What are Medicare Reason Codes?
If a Bulk Bill/DVA Claim is transmitted through to Medicare successfully, Medicare will assess the claim and either fully pay, part pay, or reject the claim. If there are errors in the claim, these are sent back to your practice with accompanying reason codes. These codes appear as Exceptions to Review.
Each exception in a claim must be dealt with before attempting to receipt off the claim.
Below is a list of some common exceptions and our suggested solutions.
To view the exceptions, ensure you have the correct claim highlighted in Exceptions to Review, then click Review Exceptions.
| Reason Code | Description | What it means | Genie Solution |
|---|---|---|---|
| 154 | Diagnostic imaging multiple service rule applied to service | The Diagnostic imaging multiple service rule (DIMSR) was applied to this item, meaning that it was charged with another diagnostic procedure item, which consequently attracted a discounted payment from Medicare. |
As this is normally still paid by Medicare, but at a discounted rate, we suggest clicking Edit Item to open the Sales window. Click Edit, then change the Total Charge to the amount Medicare paid. Click Save, then Delete Exception. To prevent this from happening for future claims, ensure you are clicking the DIMSR button within the Invoice window. See our DIMSR article for instructions on how to do this. |
| 157 | Service possibly aftercare - refer to provider | Medicare are questioning if this item charged was part of normal aftercare of the accompanying procedural item. There may be a need to indicate that consult items were 'not normal aftercare' and as such should be paid in full. For more information on aftercare, follow this ADHS link. |
If this item is not normal aftercare and therefore applicable for payment, click Edit Item to open the Sales window. Click Edit, then check Not Normal Aftercare under Medicare Overrides. Click Save. Choose to Remove Item from Batch, Delete Exception, then re-send item in BB/DVA New Transmission window. If this item was indeed incorrectly transmitted, once you have selected to Delete Exception, then chase patient for payment, or apply a credit in Account History. This will still appear in the New Transmission window if it is addressed to Medicare/ DVA and there is no payment. |
| 160 | Maximum number of services for this item already paid | For certain MBS items, you can only claim the item a certain number of instances within a specified time period. Check the ADHS website and log into HPOS to check if this is applicable for your item. | If you are not permitted to be paid for this item, choose to Remove Item from Batch, Delete Exception, then chase patient for payment, or apply a credit in the patient's Account History. |
| 162 | Benefit has been previously paid for this service | From Medicare's perspective, this item is a duplicate of a previous service already charged on the same service date. |
If you have checked the patient's Account History and this is not a duplicate service, check your bank records and contact Medicare for a remittance advice for proof of payment. Once you have spoken to Medicare and confirmed whether this was paid on a previous batch, please contact Genie Support for further instruction. |
| 255 | Benefit assigned has been increased | Medicare have paid the item, however they have paid it per the Fee Schedule that was current as at the Service Date. This occurs generally when the MBS has been updated by Medicare, however, this has not been updated within your Genie via Special > Software Updates. |
Click Edit Item to open the Sales window. Click Edit, then change the Total Charge to match the amount Medicare paid. Click Save, then choose to Delete Exception. To prevent this from happening for future claims, ensure that your Medicare/DVA billing is done in a timely manner, and your Medicare Schedule is kept up to date. Please see our Fee Schedule Status article to be review when a new fee schedule has been released for Medicare. |
| 536 | Location specific practice number not supplied | The LSPN is used to identify practice sites that provide diagnostic imaging services. This reason code suggests that the LSPN has not been entered against the Site of Service attached to this invoice. To find out your LSPN, please visit this ADHS web page. |
Click Remove Item from Batch and Delete Exception. Add the LSPN to the doctor's User Preferences. Navigate to patient's Account History, double-click on the invoice and re-select the Site of Service to ensure it picks up the LSPN then click Save. Re-send item in a new BB/DVA New Transmission window. |
| 600 | Requesting/referring provider unable to be identified | The details listed for the requesting/referring provider attached to the claim are unable to be identified. | Contact the referring/requesting provider for valid and correct details. Once correct provider details obtained and corrected in Edit Patient Details, click Remove Item from Batch, then Delete Exception. Navigate to patient's Account History, double-click on the invoice and re-select the Referring Doctor to ensure this picks up new details then click Save. Re-send item in BB/DVA New Transmission window. |
| 606 | Referring provider number not open at date of referral | The referring doctor's provider number was not valid at the issue date shown in Genie. | Follow up with the referring doctor to find out if they had another provider number at the time of service, or the patient has an alternate referral. Edit the referral information in Edit Patient Details if incorrect. Remove Item from Batch, Delete Exception, then navigate to patient's Account History, double-click on the invoice and re-select the Referring Doctor to ensure this picks up the new information then click Save. Re-send item in BB/DVA New Transmission window. |
| 619 | Servicing provider number not open at date of service | The servicing doctor's provider number was not valid at the time of the Service Date shown in Genie. | Remove Item From Batch and Delete Exception. Check your doctor's provider number. If the incorrect provider number is listed, edit the provider number for this practice site (see Add a Site of Service). Navigate to patient's Account History, double-click on the invoice and re-select the Site of Service to ensure it picks up the provider number then click Save. Re-send item in BB/DVA New Transmission window. |