RFI Browser

Back  RFI # 171: 835 adjustment reason codes

Formal vs. Informal Help Informal Formal

Submitter

stacey alsdurf

Description

Our testing software indicates that the same claim adjustment reason code cannot be repeated within a CAS segment (HIPAA syntax error). I cannot see a clear reference to this issue in the implementation guides. Is this truly an error? If so, where is this issue clearly explained?

Submitter Assigned Keywords

835 Claim adjustment reason code usage

Response

This issue is addressed in multiple locations. Section 2.2.4 on page 24 states "...each CAS can report up to six different adjustments...". On pages 98-100 and 151-153 the notes for the Claim Adjustment Reason Codes (CARC) read "Used when additional adjustments apply...". The intent is that these represent different adjustments. Since the adjustment is defined by the CARC, repeating the same code would not constitute a different adjustment. If the payer's system reports multiple parts of a particular adjustment type separately, these must be combined into a single adjustment trio. From a business perspective, the receiver can not distinguish a difference between adjustments with the same CARC. The only time a given CARC can be repeated is when one part belongs in one Claim Adjustment Group Code and the rest belongs under a different Code.
If you feel that the different parts are separate things that must be differentiated, try making a case for an additional code to the list maintenance committee.
Submission 1/5/2005
Status Date 3/16/2005
Status F - Final
Primary References
Document 004010X091A1
SectionDETAIL
Page95
Set ID835
Table2
Loop2100
Segment IDCAS
Industry NameCLAIM ADJUSTMENT REASON CODE
External Code List139