PR-247: Deductible for Professional Service in Institutional Setting

What Does PR-247 Mean?

When paired with Group Code PR, the deductible amount is the patient's financial responsibility. This is the standard and expected group code for CARC 247 — the patient owes this amount as part of their Medicare cost-sharing obligation for professional services in the bundled payment episode.

CARC 247 identifies the patient's deductible obligation for a professional service that was provided in an institutional setting and billed on an institutional claim. This code is specific to Medicare bundled payment programs established under the Affordable Care Act (PPACA), such as the Bundled Payments for Care Improvement (BPCI) initiative.

In a bundled payment arrangement, Medicare makes a single payment covering all services during an episode of care. When a professional service (such as a physician's evaluation or procedure) is performed within an institutional setting and billed on the facility's claim, the patient's deductible still applies. CARC 247 isolates this deductible amount so the provider knows exactly how much to collect from the patient for the professional component.

This code appears only in the context of Medicare bundled payment programs. The deductible amount follows the standard Medicare Part A or Part B deductible rules, depending on the service type within the bundled episode.

Common Causes

How to Resolve

1. Verify deductible accuracy Confirm the patient's deductible status with Medicare and verify the applied amount is correct based on the patient's deductible accumulation.
2. Confirm bundled payment context Verify the claim falls within a Medicare bundled payment episode.
3. Issue patient statement Send the patient a statement for the deductible amount, clearly explaining it is their cost-sharing obligation under Medicare.
4. Contact Medicare contractor if incorrect If the deductible amount appears wrong, contact the MAC with the patient's deductible accumulation records for verification.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-247:

How to Prevent PR-247

• Verify patient deductible status before providing services in bundled payment episodes
• Inform patients about deductible obligations for professional services in institutional settings during pre-service financial counseling
• Track patient deductible accumulation during bundled payment episodes to set accurate collection expectations

General Prevention

• Verify patient deductible status before services in bundled payment episodes
• Inform patients about deductible obligations for professional services in institutional settings
• Track patient deductible accumulation during bundled payment episodes

Also Filed As

The same CARC 247 may appear with different Group Codes:

Related Denial Codes