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
#>
#> $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 rowsMedical 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:
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.
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