Identifying Claim Adjustment Reason Codes and Remark Codes

In the first part of this assignment you will be matching adjustment reason codes with the following situations. See pages 413-415 in your book for Claim Adjustment Reason Codes

1. $25 deductible

2. Billed a colonoscopy and biopsy without the 59 modifier (failed to follow CCI edits)

3. You found out after billing the patient for 6 months that they had BCBS insurance. BCBS only allows 4 months to submit claims.

4. Patient's insurance ended 3/31 and we billed $600 for services 4/2

5. A physician interpreted an EKG at 12:02AM 4/30. Patient died at 11:59 PM 4/29

6. Billed Medica $100. Patient has met their deductible and has an 80/20 plan. How would they deny the $20

7. Keyed a diagnosis of abnormal menstruation on a male physical in error

8. Coordination of benefits issue

9. We obtained a prior authorization for surgery but didn't include it on the claim

10. BCBS denied indicating auto should be paying the claim

Using the same link as above, indicate what should be done for each of the following situations: appeal the claim, write it off, bill the patient, or resubmit the claim. Remember that when a claim is rejected, the provider may correct and resubmit the claim, but it cannot be appealed. When a claim is denied, the provider cannot resubmit the claim but can appeal the decision.

1. A claim paid zero dollars by the insurance company. Reason code is PR-01. What should be done?

2. A claim was rejected. Reason code is CO-04. What should be done?

3. A claim was denied. Reason code is CO-29. What should be done?

4. A claim was denied. You believe is was submitted correctly. Reason code is CO-P2. What should be one? (P2 is not found in your book - P2 reads "Not a work related injury/illness and thus not the liability of the workers' compensation carrier")

5. A claim was rejected. Reason code is CO-15. What should be done?

6. A claim was denied. You feel it was submitted correctly. Reason code is CO-22. What should be done?

7. A claim was denied. Reason code is 27. What should be done?

8. A claim was rejected. Reason code is 10. What should be done?

9. A claim was partially paid. Reason code is 2. What should be done?

For the second part of this assignment I would like you to look up various remark codes, explain what they mean in your own words and then give an example of when this code might be used to deny a claim. Click on the link below and then click on Remittance Advice Remark Codes. These codes give more information and explanation for an adjustment already describe by a Claim Adjustment Reason Code or give information about the remittance processing.

https://nex12.org/index.php/codes

1. Explain and give a specific example of M77
2. Explain and give a specific example of M15
3. Explain and give a specific example of N20
4. Explain and give a specific example of N36