CARC 219 Active

PR-219: Based on Extent of Injury

TL;DR

The patient owes for treatment that exceeded the payer's injury assessment. Collect from the patient.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-219 Mean?

With PR (Patient Responsibility), the patient is responsible for treatment costs that exceed what the payer considers appropriate for the injury's extent.

CARC 219 indicates the payer reduced or denied the claim based on their determination of the extent of the patient's injury. This code is most common in workers compensation and liability insurance contexts where the payer evaluates the severity of the injury and the appropriateness of treatment relative to that severity.

The payer may have determined that the treatment provided exceeded what was reasonable given the injury's extent, or that the injury has reached maximum medical improvement (MMI) and further treatment is not warranted. This code often involves clinical assessment by the payer's medical review team.

How to Resolve

  1. Communicate with the patient Explain the payer's determination and the resulting financial responsibility.
  2. Collect from the patient Send a statement and collect the balance.
Do Not Appeal This Code

Based on Extent of Injury grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

How to Prevent PR-219

Also Filed As

The same CARC 219 may appear with different Group Codes:

CO-219 OA-219

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  3. https://www.wcb.ny.gov/CMS-1500/WCB-CARC-RARC-codes.pdf
  4. Codes maintained by X12. Visit x12.org for official definitions.