What are EOB Claim Adjustment Group Codes?

A Claim Adjustment Group Code consists of two alpha characters that assign the responsibility of a Claim Adjustment on the insurance Explanation of Benefits.

These 5 EOB Claim Adjustment Group Codes are:

CO	Contractual Obligation
CR	Corrections and Reversal
OA	Other Adjustment
PI	Payer Initiated Reductions
PR	Patient Responsibility

These Group Codes are combined with Claim Adjustment Reason Codes that can be numeric or alpha-numeric, ranging from 1 to W2. Claim Adjustment Reason Codes are associated with an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Top 5 examples of EOB Claim Adjustments are:

CO-45 indicates claim amount that must be written off based on payer contracted fee schedule.

CO-97 indicates the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

OA-23 indicates the impact of prior payer(s) adjudication including payments and/or adjustments.

PR-1 indicates amount applied to patient deductible.

PR-2 indicates amount applied to patient co-insurance.

For a complete list of claim adjustment reason codes, visit Washington Publishing Company's website by clicking here.

Let's look at Claim Scrubbers and how they function to optimize reimbursement of medical claims.

Let's look at Claim Scrubbers and how they function to optimize reimbursement of medical claims.

The best medical billing software will have a built in scrubber that analyzes the procedure codes on the claim for any conflicts to the NCCI edits.

If the scrubber finds no conflicts, then you can proceed with submitting your claim without any changes or corrections.  If the scrubber does show conflicts between two or more codes, then you now have the opportunity to review and adjust your claim before it is denied.

The billing software should indicate why there is a conflict and maybe all that is needed is a modifier.  For example, if it states one procedure is a component of the "larger" procedure, you know to not submit the component procedure.

When you submit a claim that is denied based solely on lack of a proper modifier, you then have to resumbit a "corrected claim".  Even thought they are indicated as a "corrected claim", you can now enter the duplicate claim denial loop. You may end up waiting months for reimbursement and wasting countless hours working with the payer to get the claim paid.  By taking a few minutes to "pre-check" the claim, all this would be avoided.

Investing in a medical billing system with an integrated claims scrubber you will see greater and faster returns in the reimbursement of medical claims.