STANDARD DATA DICTIONARY #161.91 -- ADJUSTMENT REASON FILE 3/24/25 PAGE 1
STORED IN ^FB(161.91, (367 ENTRIES) SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 3.5)
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This file contains a list of claim adjustment reason codes. These codes are used to indicate why the amount paid is different from
the amount billed on a health care claim. The source of the codes is the National Health Care Claim Payment/Committee Bulletins.
It is available from Washington Publishing Company. The associated suspend code, suspension description, and applicability for use
by VA on fee claims is provided by the Fee Replacement Project Management Office in Denver which represents the VA Chief Business
Office.
This file is exported with data and the contents should not be locally modified.
DD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
IDENTIFIED BY:
"CDES": D ARCDES^FBUTL3
POINTED TO BY: ADJUSTMENT REASON field (#.01) of the ADJUSTMENT sub-field (#162.07) of the SERVICE PROVIDED sub-field (#162.03) of
the INITIAL TREATMENT DATE sub-field (#162.02) of the VENDOR sub-field (#162.01) of the FEE BASIS PAYMENT File
(#162)
ADJUSTMENT REASON field (#.01) of the ADJUSTMENT sub-field (#162.14) of the PRESCRIPTION NUMBER sub-field (#162.11)
of the FEE BASIS PHARMACY INVOICE File (#162.1)
ADJUSTMENT REASON field (#.01) of the ADJUSTMENT sub-field (#162.558) of the FEE BASIS INVOICE File (#162.5)
CROSS
REFERENCED BY: CODE(B)
LAST MODIFIED: JAN 30,2018@14:48:55
161.91,.01 CODE 0;1 FREE TEXT (Required)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1)!'(X'?1P.E) X
LAST EDITED: JUN 16, 2003
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION:
Code value.
CROSS-REFERENCE: 161.91^B
1)= S ^FB(161.91,"B",$E(X,1,30),DA)=""
2)= K ^FB(161.91,"B",$E(X,1,30),DA)
161.91,1 STATUS EFFECTIVE DATE 1;0 DATE Multiple #161.911
161.911,.01 STATUS EFFECTIVE DATE 0;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:3991231X) X
LAST EDITED: JUN 18, 2003
HELP-PROMPT: TYPE A DATE BETWEEN 6/1/2003 AND 12/31/2099
DESCRIPTION:
Effective date of status.
CROSS-REFERENCE: 161.911^B
1)= S ^FB(161.91,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^FB(161.91,DA(1),1,"B",$E(X,1,30),DA)
161.911,1 STATUS 0;2 SET
'0' FOR INACTIVE;
'1' FOR ACTIVE;
LAST EDITED: JUN 16, 2003
HELP-PROMPT: Specify the status of the code as of the effective date.
DESCRIPTION: The status of the claim adjustment reason code as of the effective date. It will be used to
prevent inactive codes from being specified during adjudication of a claim.
161.911,2 FEE USE 0;3 SET
'0' FOR NOT APPLICABLE;
'1' FOR APPLICABLE;
LAST EDITED: JUN 16, 2003
HELP-PROMPT: Specify applicability of use with fee claims as of effective date.
DESCRIPTION: Indicates if code is applicable for use on fee claims as of effective date. (1 applicable or 0
not applicable) It will be used to prevent inappropriate codes from being specified during
adjudication of a claim.
161.91,2 DESCRIPTION EFFECTIVE DATE 2;0 DATE Multiple #161.912
161.912,.01 DESCRIPTION EFFECTIVE DATE 0;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:3991231X) X
LAST EDITED: JUN 18, 2003
HELP-PROMPT: TYPE A DATE BETWEEN 6/1/2003 AND 12/31/2099
DESCRIPTION:
Effective date of description.
CROSS-REFERENCE: 161.912^B
1)= S ^FB(161.91,DA(1),2,"B",$E(X,1,30),DA)=""
2)= K ^FB(161.91,DA(1),2,"B",$E(X,1,30),DA)
161.912,1 DESCRIPTION D;0 WORD-PROCESSING #161.9121
LAST EDITED: JUN 16, 2003
HELP-PROMPT: Enter the description of the adjustment reason code as of the effective date.
DESCRIPTION: The description of the adjustment reason code as of the effective date. It will be used to
display a description of the code.
161.91,3 ASSOCIATED SUSPEND CODE 0;2 POINTER TO FEE BASIS SUSPENSION FILE (#161.27)
LAST EDITED: JUN 16, 2003
HELP-PROMPT: Select a suspend code that is associated with the adjustment code.
DESCRIPTION: This field should be populated for every adjustment code that is currently applicable for use on
fee claims. The software will automatically copy this value to the SUSPEND CODE field in an
invoice file after the adjustment reason code is specified for the invoice. If more than one
adjustment reason is specified, the one with the largest dollar impact will be used to determine
the suspend code.
161.91,4 SUSPENSION DESCRIPTION 4;0 WORD-PROCESSING #161.914
LAST EDITED: JUN 16, 2003
HELP-PROMPT: Enter description of suspension when associated suspend code is Other.
DESCRIPTION: This field should be populated with a description of the adjustment reason when the associated
suspend code is Other. The system will automatically copy this text to the DESCRIPTION OF
SUSPENSION field in an invoice file.
161.91,5 REMITTANCE REMARK RARC;0 POINTER Multiple #161.915 (Add New Entry without Asking)
DESCRIPTION: This field contains the sub-set of remittance remarks allowed for this adjustment reason. It should
only be modified when updated adjustment reason and remittance remark codes, and their
relationships, are released.
161.915,.01 REMITTANCE REMARK 0;1 POINTER TO REMITTANCE REMARK FILE (#161.93) (Multiply asked)
LAST EDITED: MAR 06, 2015
HELP-PROMPT: Enter an existing Remittance Remark Code
DESCRIPTION: This field holds the REMITTANCE REMARK associated with the ADJUSTMENT REASON. Only these
remittance remarks are listed during a FileMan lookup, if defined.
CROSS-REFERENCE: 161.915^B
1)= S ^FB(161.91,DA(1),"RARC","B",$E(X,1,30),DA)=""
2)= K ^FB(161.91,DA(1),"RARC","B",$E(X,1,30),DA)
161.91,6 CORE SCENARIO 0;3 SET
'1' FOR Incorrect Documentation;
'2' FOR Incorrect Claim Data;
'3' FOR Billed Service Not Covered;
'4' FOR Benefit for Service Not Payable;
LAST EDITED: JUN 13, 2016
HELP-PROMPT: Enter the CAQH CORE Code Combinations Scenario Number.
DESCRIPTION: Used to indicate what business scenario, associated with Phase III CORE 360 Rule, this adjustment
reason code is associated with, if any.
161.91,7 ADJUSTMENT GROUP 3;0 POINTER Multiple #161.917 (Add New Entry without Asking)
DESCRIPTION:
Some CARCs have GROUP restrictions. Specify the allowable GROUPS for this CARC here.
161.917,.01 ADJUSTMENT GROUP 0;1 POINTER TO ADJUSTMENT GROUP FILE (#161.92) (Multiply asked)
LAST EDITED: JUL 14, 2016
HELP-PROMPT: Enter an ADJUSTMENT GROUP (#161.93)
CROSS-REFERENCE: 161.917^B
1)= S ^FB(161.91,DA(1),3,"B",$E(X,1,30),DA)=""
2)= K ^FB(161.91,DA(1),3,"B",$E(X,1,30),DA)
FILES POINTED TO FIELDS
ADJUSTMENT GROUP (#161.92) ADJUSTMENT GROUP:ADJUSTMENT GROUP (#.01)
FEE BASIS SUSPENSION (#161.27) ASSOCIATED SUSPEND CODE (#3)
REMITTANCE REMARK (#161.93) REMITTANCE REMARK:REMITTANCE REMARK (#.01)
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