Although CARC 96/RARC N431 is a valid combination per CAQH, does this CARC/RARC combination match the below CMS denial rationale?
• CMS Rationale: CMS designates service as noncovered as per status N as per Medicare Physician Fee Schedule (MPFS).
• Since CARC 96 cannot be a stand-alone CARC, I have to assign a RARC to it, but there is no RARC that says, "not covered per Medicare" or "Medicare noncovered service", so I am asking if there is a better RARC to assign then RARC N431?
Per CMS.gov: Physician Fee Schedule - January 2024 release (https://www.cms.gov/files/zip/rvu24a-updated-01/03/2024.zip), CPT code 99401 is a non-covered service.
• Payer uses deny EX code 490 to deny CPT 99401 which is assigned CARC 96 (non-covered charge), RARC N431 (not covered with this procedure) and CO (Contractual Obligation).
It is not within X12’s purview to comment on the usage of CARC or RARC codes. X12 cannot comment on an entity’s policy/contracts or procedure for denying claims and the usage of adjustment codes.