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Adjustment Codes

search_adjustments()
#> # A tibble: 1,581 × 8
#>    adj_code adj_type adj_description          adj_usage adj_notes adj_start_date
#>    <chr>    <chr>    <chr>                    <chr>     <chr>     <date>        
#>  1 CO       Group    Contractual Obligations  NA        NA        NA            
#>  2 CR       Group    Corrections and Reversa… NA        NA        NA            
#>  3 OA       Group    Other Adjustments        NA        NA        NA            
#>  4 PI       Group    Payer Initiated Reducti… NA        NA        NA            
#>  5 PR       Group    Patient Responsibility   NA        NA        NA            
#>  6 1        CARC     Deductible Amount        NA        NA        1995-01-01    
#>  7 2        CARC     Coinsurance Amount       NA        NA        1995-01-01    
#>  8 3        CARC     Co-payment Amount        NA        NA        1995-01-01    
#>  9 4        CARC     The procedure code is i… Refer to… NA        1995-01-01    
#> 10 5        CARC     The procedure code/type… Refer to… NA        1995-01-01    
#> 11 6        CARC     The procedure/revenue c… Refer to… NA        1995-01-01    
#> 12 7        CARC     The procedure/revenue c… Refer to… NA        1995-01-01    
#> 13 8        CARC     The procedure code is i… Refer to… NA        1995-01-01    
#> 14 9        CARC     The diagnosis is incons… Refer to… NA        1995-01-01    
#> 15 10       CARC     The diagnosis is incons… Refer to… NA        1995-01-01    
#> 16 11       CARC     The diagnosis is incons… Refer to… NA        1995-01-01    
#> 17 12       CARC     The diagnosis is incons… Refer to… NA        1995-01-01    
#> 18 13       CARC     The date of death prece… NA        NA        1995-01-01    
#> 19 14       CARC     The date of birth follo… NA        NA        1995-01-01    
#> 20 15       CARC     The authorization numbe… NA        NA        1995-01-01    
#> # ℹ 1,561 more rows
#> # ℹ 2 more variables: adj_last_modified <date>, adj_end_date <date>

Denials

search_denials()
#> $site
#> # A tibble: 64 × 5
#>    adj_code denial_reason        common_reasons next_steps claim_submission_tips
#>    <chr>    <chr>                <chr>          <chr>      <chr>                
#>  1 CO-16    Missing/Incorrect R… Information r… Submit ne… Ensure procedure cod…
#>  2 M51      Missing/Incorrect R… Information r… Submit ne… Ensure procedure cod…
#>  3 N56      Missing/Incorrect R… Information r… Submit ne… Ensure procedure cod…
#>  4 CO-16    Code to Highest Lev… Truncated (in… Verify di… To avoid scanning er…
#>  5 M81      Code to Highest Lev… Truncated (in… Verify di… To avoid scanning er…
#>  6 CO-16    Medicare is Seconda… Incorrect pri… Verify wh… Prior to submitting …
#>  7 MA04     Medicare is Seconda… Incorrect pri… Verify wh… Prior to submitting …
#>  8 CO-16    Invalid Patient Name Patient name … Verify th… Obtain patient's ful…
#>  9 MA36     Invalid Patient Name Patient name … Verify th… Obtain patient's ful…
#> 10 N704     Invalid Patient Name Patient name … Verify th… Obtain patient's ful…
#> 11 CO-16    CLIA Certification … CLIA certific… Resubmit … Apply for CLIA Certi…
#> 12 MA120    CLIA Certification … CLIA certific… Resubmit … Apply for CLIA Certi…
#> 13 CO-16    Chiropractic Servic… Initial treat… Resubmit … Paper submitters: Se…
#> 14 MA121    Chiropractic Servic… Initial treat… Resubmit … Paper submitters: Se…
#> 15 MA122    Chiropractic Servic… Initial treat… Resubmit … Paper submitters: Se…
#> 16 N264     Missing or Invalid … NA             NA         NA                   
#> 17 N265     Missing or Invalid … NA             NA         NA                   
#> 18 CO-16    Missing or Invalid … NA             NA         NA                   
#> 19 CO-16    Missing/Incorrect R… Missing or in… Verify su… Rendering NPI must b…
#> 20 N290     Missing/Incorrect R… Missing or in… Verify su… Rendering NPI must b…
#> # ℹ 44 more rows
#> 
#> $site2
#> # A tibble: 53 × 5
#>    carc  rarc       claim_type      reasons                          resolutions
#>    <chr> <chr>      <fct>           <chr>                            <chr>      
#>  1 109   NA         All             The beneficiary was enrolled in… A claim fo…
#>  2 16    MA04       MSP             Medicare is the beneficiary's s… Resubmit t…
#>  3 16    MA48, N211 MSP             Medicare is the beneficiary's s… Gather acc…
#>  4 16    N245, N211 MSP             Medicare is the beneficiary's s… Gather acc…
#>  5 16    N480       MSP             Medicare is the beneficiary's s… Submit an …
#>  6 19    NA         MSP             Medicare is the beneficiary's s… Resubmit t…
#>  7 19    N728       MSP             Medicare is the beneficiary's s… Submit an …
#>  8 20    MA04       MSP             Medicare is the beneficiary's s… Resubmit t…
#>  9 20    N725       MSP             Medicare is the beneficiary's s… Submit an …
#> 10 201   MA01, N722 MSP             The beneficiary's primary insur… Submit an …
#> 11 201   N724       MSP             The beneficiary's primary insur… Submit an …
#> 12 21    NA         MSP             Medicare is the beneficiary's s… Resubmit t…
#> 13 21    N727       MSP             Medicare is the beneficiary's s… Submit an …
#> 14 22    NA         MSP             Medicare is the beneficiary's s… Gather acc…
#> 15 22    MA16       MSP             The beneficiary is covered unde… Gather acc…
#> 16 246   N620       All             The claim was billed with a pro… If it was …
#> 17 26    NA         Medicare Part B The beneficiary's did not have … Validate t…
#> 18 50    N115       All             The claim was submitted with in… Please ref…
#> 19 96    N56, N211  All             The procedure/service that was … Resubmit t…
#> 20 97    M80        All             The service billed on the claim… Review all…
#> # ℹ 33 more rows
#> 
#> $ext
#> # A tibble: 58 × 3
#>    adj_code denial_type denial_category                 
#>    <chr>    <chr>       <chr>                           
#>  1 29       Technical   Past Timely Filing Limits       
#>  2 119      Technical   Patient Liability               
#>  3 A1       Clinical    Informational                   
#>  4 18       Technical   Duplicate Claim                 
#>  5 50       Clinical    Medical Necessity               
#>  6 96       Clinical    Non-Covered Service             
#>  7 129      Technical   Billing Error: Invalid Code     
#>  8 16       Technical   Additional Information Requested
#>  9 B13      Technical   Duplicate Claim                 
#> 10 226      Clinical    Additional Information Requested
#> 11 252      Clinical    Additional Information Requested
#> 12 4        Clinical    Billing Error: Invalid Code     
#> 13 146      Clinical    Billing Error: Invalid Code     
#> 14 197      Clinical    Invalid/Missing Authorization   
#> 15 236      Clinical    Bundling                        
#> 16 199      Clinical    Billing Error: Invalid Code     
#> 17 250      Clinical    Additional Information Requested
#> 18 6        Clinical    Billing Error: Invalid Code     
#> 19 96       Technical   Non-Covered Service             
#> 20 286      Clinical    Medical Necessity               
#> # ℹ 38 more rows

Medical billing adjustment codes, also known as Claim Adjustment Reason Codes (CARCs), are used by healthcare payers to explain why a claim or service line was paid differently than it was billed. These codes provide specific reasons for adjustments made to the payment amount, such as deductibles, coinsurance, contractual obligations, or other adjustments.

Claim Adjustment Reason Codes (CARCs)

Group Codes and Claim Adjustment Reason Codes (CARCs) serve distinct but complementary purposes in medical billing and remittance advice:

Group Codes

Group Codes identify the general category or high-level reason for a payment adjustment. They provide an overarching classification for the type of adjustment being made. The main Group Codes are:

  • CO (Contractual Obligation): Adjustment due to a contractual agreement or regulatory requirement, typically a write-off for the provider.
  • OA (Other Adjustment): Used when no other group code applies to the adjustment.
  • PR (Patient Responsibility): Adjustment representing an amount that should be billed to the patient, such as deductibles or copays.
  • PI (Payer Initiated Reductions): Adjustment initiated by the payer when they believe the provider is financially liable, but there is no supporting contract.

A Group Code must always be used in conjunction with a Claim Adjustment Reason Code to provide the specific reason for the adjustment.

Claim Adjustment Reason Codes (CARCs)

CARCs are more granular, three-character alphanumeric codes that describe the precise reason why a claim or service line was paid differently than it was billed. They provide detailed explanations for adjustments, such as:

  • CO-16: Claim lacks information needed for adjudication.
  • PR-1: Deductible amount.
  • OA-23: Charges have been unbundled.

While Group Codes categorize the general type of adjustment, CARCs give the exact rationale behind each specific payment adjustment made to a claim line or claim. The combination of a Group Code and CARC fully communicates the nature and responsibility for any differences between the billed and paid amounts.

Remittance Advice Remark Codes (RARCs)

The purpose of Remittance Advice Remark Codes (RARCs) is to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

Specifically, RARCs serve two main functions:

  1. Supplemental RARCs provide additional details or clarification for an adjustment that has already been described by a CARC. For example, a CARC may indicate that a claim was denied due to missing information, and a supplemental RARC would further specify what exact information was missing.

  2. Informational RARCs, prefaced with “Alert:”, convey information about the remittance processing itself, rather than being related to a specific adjustment or CARC. These alerts communicate things like changes to procedure codes, potential impacts on patient liability, or other processing details.

In summary, while CARCs explain the reason for an adjustment to a claim payment, RARCs give additional context, details, or processing information related to those adjustments or the remittance advice as a whole. The combination of CARCs and RARCs allows for clear communication between payers and providers regarding claim adjudication decisions.

https://med.noridianmedicare.com/web/jeb/topics/ra https://www.palmettogba.com/palmetto/jmb.nsf/DID/2NF7NSFT1B https://files.ontario.ca/moh_1/moh-remittance-advice-explanatory-codes-2022-12-en-2023-05-15.pdf https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00243417