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Last Modified: 5/15/2020 Location: FL, PR, USVI Business: Part A

Avoiding return to provider (RTP) reason code 12206 FAQ

Q: We received an RTP with reason code 12206. What steps can we take to avoid this RTP?
Click here for a description associated with Medicare Part A reason code(s). Enter the reason code into the box and click the submit button.
A: You received this RTP because the total number of covered and non-covered days on the claim is not equal to the total number of days in the statement covers “From” and “Through” dates.
The total number of days reported on the claim must match the number of days for the statement coverage period.
Verify the number of days reported for the statement coverage “From” and “Through” dates. The statement coverage “Through” date should be counted only if the patient status is 30 (beneficiary is still a patient).
Verify the number of covered and non-covered days reported.
Covered and non-covered days are reported by using value codes. Please refer to the following list of value codes and descriptions.
Value code 80 -- Covered days
The number of days covered by the primary payer as qualified by the payer

Note:
Value code 80 is used to report a combined total of the beneficiary’s full days and coinsurance and lifetime reserve days, as applicable.
Value code 81 -- Non-covered days
Days of care not covered by the primary payer
Value code 82 -- Co-insurance days
The inpatient Medicare days occurring after the 60th, and before the 91st day, or inpatient SNF/Swing bed days occurring after the 20th, and before the 101st, day in a single spell of illness
Value code 83 -- Lifetime reserve days
Under Medicare, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services, available to use after 90 consecutive days of inpatient hospital services during a spell of illness
Example 1:
Statement Coverage “From” Date: 01/01/XX
Statement Coverage “Through” Date: 01/31/XX
Patient Status is not 30*
Covered (value code 80) + non-covered (value code 81) days = 30 (*Through date is not counted.)
Example 2:
Statement Coverage “From” Date: 01/01/XX
Statement Coverage “Through” Date: 01/31/XX
Patient Status is 30*
Covered (value code 80) + non-covered (value code 81) days = 31 (*”Through” date is counted.)
Hospital providers may refer to coding examples in the CMS special edition article SE1310 – Claims Processing Instructions for Inlier Bills and Cost Outlier Bills with Benefits Exhausted external pdf file
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