Here are the top 21 claim adjustment codes, followed by reason codes, reflecting why a claim wasn't paid or was paid differently than billed.
These codes pertain to claims for all specialties across the country from April 23 through July 30. Data is based on RemitDATA database, which houses 25 percent of all national outpatient remittances.
Adjustment code followed by reason code descriptions:
1. Contractual obligations. Duplicate claim/service.
2. Contractual obligations. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
3. Contractual obligations. Claim/service lacks information which is needed for adjudication. At least one remark code must be provided.
4. Other adjustments. Duplicate claim/service.
5. Contractual obligations. These are noncovered services because this is not deemed a "medical necessity" by the payor.
6. Patient responsibility. Expenses incurred after coverage terminated.
7. Contractual obligations. The time limit for filing has expired.
8. Payor initiated reductions. Duplicate claim/service.
9. Contractual obligations. Claim/service denied. At least one remark code must be provided.
10. Other adjustments. Claim not covered by this payor/contractor. You must send the claim to the correct payor/contractor.
11. Contractual obligations. Non-covered charges. At least one remark code must be provided.
12. Contractual obligations. Claim not covered by this payor/contractor.
13. Contractual obligations. This care may be covered by another payor per coordination of benefits.
14. Contractual obligations. This provider was not certified to be paid for this procedure/service on this date of service.
15. Patient responsibility. Claim/service lacks information which is needed for adjudication. At least one remark code must be provided.
16. Contractual obligations. This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure
has not been received/adjudicated.
17. Contractual obligations. Submission/billing error(s). At least one remark code must be provided.
18. Contractual obligations. Previously paid. Payment for this claim/service may have been provided in a previous payment.
19. Contractual obligations. Payment adjusted because the payor deems the information submitted does not support this many/frequency of service.
20. Patient responsibility. This care may be covered by another payor per coordination of benefits.
21. Patient responsibility. Patient cannot be identified as insured.
4 Recent Disputes Over Surgery Center Payments
12 Steps to More Robust Reimbursement in a Surgery Center
These codes pertain to claims for all specialties across the country from April 23 through July 30. Data is based on RemitDATA database, which houses 25 percent of all national outpatient remittances.
Adjustment code followed by reason code descriptions:
1. Contractual obligations. Duplicate claim/service.
2. Contractual obligations. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
3. Contractual obligations. Claim/service lacks information which is needed for adjudication. At least one remark code must be provided.
4. Other adjustments. Duplicate claim/service.
5. Contractual obligations. These are noncovered services because this is not deemed a "medical necessity" by the payor.
6. Patient responsibility. Expenses incurred after coverage terminated.
7. Contractual obligations. The time limit for filing has expired.
8. Payor initiated reductions. Duplicate claim/service.
9. Contractual obligations. Claim/service denied. At least one remark code must be provided.
10. Other adjustments. Claim not covered by this payor/contractor. You must send the claim to the correct payor/contractor.
11. Contractual obligations. Non-covered charges. At least one remark code must be provided.
12. Contractual obligations. Claim not covered by this payor/contractor.
13. Contractual obligations. This care may be covered by another payor per coordination of benefits.
14. Contractual obligations. This provider was not certified to be paid for this procedure/service on this date of service.
15. Patient responsibility. Claim/service lacks information which is needed for adjudication. At least one remark code must be provided.
16. Contractual obligations. This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure
has not been received/adjudicated.
17. Contractual obligations. Submission/billing error(s). At least one remark code must be provided.
18. Contractual obligations. Previously paid. Payment for this claim/service may have been provided in a previous payment.
19. Contractual obligations. Payment adjusted because the payor deems the information submitted does not support this many/frequency of service.
20. Patient responsibility. This care may be covered by another payor per coordination of benefits.
21. Patient responsibility. Patient cannot be identified as insured.
More Articles on Claims and Billing:
AAPC: Is Your Practice Getting Paid for the Services It Performs?4 Recent Disputes Over Surgery Center Payments
12 Steps to More Robust Reimbursement in a Surgery Center