Health Care Claim Adjustment Reason Codes

$447.50 / year

This dataset explains information on Claim adjustment reason codes to communicate an adjustment, meaning that this information communicates why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Complexity

The HIPAA or Health Insurance Portability and Accountability Act of 1996, instructs medical healthcare plans to use the standard electronic transactions adopted under this agency by using the following valid standard codes. Medicare policy requires that CARCs should provide a supplemental explanation why a claim or service line was paid differently than it was billed.

The Centers for Medicare & Medicaid Services (CMS) staff usually requests changes in the code when it directly affects the Medicare policy. Shared System Maintainers (SSMs) and Medicare contractors are notified about all the necessary changes. If a modification has been implemented by an entity outside CMS for a code currently used by Medicare, Medicare Administrative Contractors (MACs) must either use the existing modified code or another code. If any new or modified code has an effective date past the implementation date specified in CR9004, MACs will implement on the date specified on the WPC website.

The Centers for Medicare & Medicaid Services (CMS) maintain and annually update a List of Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) Codes (Code List), which identifies all the items and services included within certain DHS categories. CMS updates the Code List to conform the list to the most recent publications of CPT and HCPCS and to account for changes in Medicare coverage and payment policies. The updated Code List is published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. That rule is usually published in November and generally becomes effective January 1 of the following year. In addition, we may publish other rules or correction notices that may change the Code List. CMS posts any changes to the Code List on its webpage as soon as possible after publication in the Federal Register.

The DHS categories defined by the Code List are:
– Clinical laboratory services;
– Physical therapy services, occupational therapy services, outpatient speech-language pathology services;
– Radiology and certain other imaging services; and
– Radiation therapy services and supplies.

**NOTE**: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:
– Durable medical equipment and supplies;
– Parenteral and enteral nutrients, equipment and supplies;
– Prosthetics, orthotics, and prosthetic devices and supplies;
– Home health services;
– Outpatient prescription drugs; and
– Inpatient and outpatient hospital services.

Date Created

1995

Last Modified

2020-03-03

Version

2020-03-03

Update Frequency

Irregular

Temporal Coverage

1995 to 2019

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Claim Adjustment Reason Codes, CARC, ASC X12 External Code Source 139, Medical Billing Denial Code, Medicare Reason, Medicare Denial Codes, Medicaid Denial Codes, Medicare Denials, Claims Adjustment Group, Denial Code

Other Titles

Health Insurance Portability and Accountability Act (HIPAA) Standard Electronic Transactions, Medicare Appropriate Claim Adjustment Reason Codes, Claim Adjustment Reason Codes Supplemental Explanation for Adjustments, Claim Adjustment Reason Codes Denial Transactions, List of “To be Deactivated” Claim Adjustment Reason Codes, Currently “Deactivated” Claim Adjustment Reason Codes, Medicare Reason CARC, Medicare Denials and Claim Adjustment Reason Codes, Claims Adjustment Group CARC, Denial Code and Claim Adjustment Reason Codes

NameDescriptionTypeConstraints
CodeClaim Adjustment Reason Codesstringrequired : 1 unique : 1
DescriptionDescription for each Claim Adjustment Reason Codestringrequired : 1
Start_DateDate the Claim Adjustment Reason Code started usagedaterequired : 1
Last_ModifiedDate the Claim Adjustment Reason Code was changed/modifieddate-
Stop_DateDate the Claim Adjustment Reason Code was deactivated/stoppeddate-
StatusCode update whether Active, To be Deactivated or Deactivatedstringrequired : 1
NotesExplanation to redundant and/or replacement Claim Adjustment Reason Codestring-
CodeDescriptionStart DateLast ModifiedStop DateStatusNotes
1Deductible Amount1995-01-01Active
2Coinsurance Amount1995-01-01Active
3Co-payment Amount1995-01-01Active
4The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.1995-01-012020-03-01Active
5The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.1995-01-012018-03-01Active
6The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.1995-01-012017-07-01Active
7The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.1995-01-012017-07-01Active
8The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.1995-01-012017-07-01Active
9The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present1995-01-012017-07-01Active
10The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.1995-01-012017-07-01Active