Home Health & Hospice Week

If you're trying to figure out whether your claims have been adjusted due to the outlier cap, you can check for a new RARC/CARC code combo.

When the system makes an adjustment based on the cap, it will use remittance advice reason code N523 (The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid) and the newly associated claim adjustment reason code B5 (Coverage/program guidelines were not met or were exceeded),the Centers for Medicare & Medicaid Services explains in April 28 Transmittal No. 1956 (CR 6897).

Before March 1, CMS used CARC 45. "The combination of CARC B5 and RARC N523 describes the outlier limitation more accurately,"notes the transmittal at www.cms.gov/transmittals/downloads/R1956CP.pdf.