Adjustment Reason Codes

Adjustment reason codes are required on Direct Data Entry (DDE) adjustments on type of bill (TOB) XX7 and are entered on DDE claim page 3. Adjustment Reason Codes are not used on paper or electronic claims.

X
 
Code Description
AA Automated Adjustment
AD Admission Denial - Technical Denial (Peer Review Organization (PRO) Review Code - A)
AM Admission Denial - No Payment (Medical Denial) (PRO Review Code - A)
AR Admission Reversal - Hard Copy Adjustment
AU Automobile
AW Admission Denial - Payable Per Waiver
BL Black Lung
CA Cost Outlier Approved
CB Credit Balance Accounts
CD Covered Days Changes (PRO Review Code - B)
CO Cost Outlier - No Payment (PRO Review Code - E)
CP Cost Outlier Partial Approved
CR Claim Reconsideration
CW Cost Outlier Denial - Payable Per Waiver
DA Day Outlier Approved
DB Disability
DC Diagnosis Changes (PRO Review Code - C)
DD Discharge Destination Code Changes (PRO Review Code - C)
DG Diagnosis Related Grouper (DRG) Change and Day Outlier Denial (PRO Review Code - G)
DH DRG Change and Cost Outlier Denial (PRO Review Code - H)
DI DRG and Beneficiary Liability Change (PRO Review Code - I)
DO Day Outlier Denial - No Payment (PRO Review Code - D)
DP Diagnosis and Procedure Changes (PRO Review Code - C)
DS Discharge Status Change
DV DRG Validation (PRO Review Code - C)
DW Day Outlier Denial-Payable Per Waiver
EF End Stage Renal Disease (ESRD) Adjustment Fix to Correct Original Claims
ES ESRD
FB Beneficiary Liability Change (PRO Review Code - F)
FC Home Health Prospective Payment System (HHPPS) Final claim
FD Full Denial (PRO Review Code - A)
FR Full Reversal (PRO Review Code - N)
FT Full Denial - Technical Denial (PRO Review Code - A)
HA Home Health 485/486 Postpayment Audits
HC Home Health Covered Compliance Reviews
HD Health Maintenance Organization (HMO) Disenrollment
HP HMO Pay
IB Prospective Payment System (PPS) Interim Bill
IC Non-Billable Revenue Codes Invalid Revenue Codes
ID Inpatient or Blood Deductible
JP Deemed Admission Change in Days (PRO Review Code - J)
KB Deemed Admission Change in Days (PRO Review Code - J)
KD Deemed Admission/Diagnosis Code Change (PRO Review Code - K)
KP Deemed Admission/Procedure Code Change (PRO Review Code - K)
LD Deemed Admission/Day Outlier Denial (PRO Review Code - L)
LI Liability
LS Length of Stay Denial-No Payment
LW Length of Stay Denial-Payable Per Waiver
MC Deemed Admission/Cost Outlier Denial (PRO Review Code - M)
MR Medical Review
NF HHPPS No Final Claim
OC Procedure Codes Changed, Denied, or Added (PRO Review Code - R)
OP Day Outlier Approved
OT Other Change
PC Procedure Changes (PRO Review Code - C)
PD Procedural Denial - No Payment
PH Public Health Service (PHS) MSP Value Code 16
PI Program Integrity
PN Provider Number Change
PP Discharge Status Change (PRO Review Code - P)
PR Previous Adjustment Modified (Modifies the PROs Last Action) (PRO Review Code - O)
PT Admission Denial and DRG Change (PRO Review Code - T)
PW Procedural Denial - Payable Per Waiver
QC Procedure Codes (HCPCS) Changed/Deleted/Added (PRO Review Code - R)
QD Ancillary Services Denied or Approved (PRO Review Code - Q)
QR HCPC Added/Deleted/Changed with Ancillary Change (PRO Review Code-S)
R1 Reopening Performed within 1 Year of the Date of the Initial Determination
R2 Reopening Performed Greater than 1 Year and up to 4 years from the Date of the Initial Determination
R3 Reopening Performed Greater than 4 Years of the Date of the Initial Determination
RI Recovery Audit Contractor (RAC) Identified Overpayment
RC Complete Reversal of Previous Adjustment (PRO Review Code - N)
RP Partial Reversal of Previous Adjustment (PRO Review Code - O)
SB Same Benefit Period
SD Seven Day Readmission Denial
SW Seven Day Re-admission Denial - Payable Per Waiver
SQ Qualified Independent Contractor
TD Transfer Denial - No Payment
TW Transfer Denial - Payable Per Waiver
VA Veteran's Administration
WC Worker's Compensation
WE Working Elderly
YA Pacemaker Denial - No Data
YB Pacemaker Denial - With Errors
YC Pacemaker Reversal to Denial
YD Pacemaker Reversal to Denial and not going to pay
ZW Debit Adjustment being processed for Provider and Intermediary and an initial bill is being processed to Common Working File (CWF)

 

Last Updated Wed, 26 Sep 2018 09:10:40 +0000