CARC 60 Active

PR-60: Outpatient Services Not Covered Near Inpatient Stay

TL;DR

Patient responsibility — review the adjustment and determine if the patient truly owes this amount.

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-60 Mean?

With PR (Patient Responsibility), the CARC 60 adjustment for outpatient services not covered near inpatient stay shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

CARC 60 indicates outpatient services not covered near inpatient stay. The payer's adjudication logic determined that this service or procedure is included within another service that was billed on the same claim or a related claim.

Common scenarios that trigger this adjustment include: outpatient services provided within 3 days (1 day for non-IPPS hospitals) before an inpatient admission are bundled into the inpatient DRG payment; Outpatient services within the payment window after inpatient discharge are bundled into the inpatient claim; Pre-admission tests performed near the admission date are included in the inpatient payment. The group code paired with CARC 60 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

How to Resolve

  1. Review the adjustment Examine the PR-60 adjustment and any RARC codes to understand the basis for the patient responsibility.
  2. Verify the adjustment is correct Confirm the PR designation and amount are appropriate based on the patient's plan benefits.
  3. Appeal if incorrect If the adjustment appears incorrect, file an appeal with supporting documentation.
  4. Collect from the patient if valid If the adjustment is confirmed correct, generate a patient statement and follow standard collection procedures.
Do Not Appeal This Code

Outpatient Services Not Covered Near Inpatient Stay reflects a service that falls outside covered benefits, with the patient held responsible. Coverage decisions per plan terms generally aren't appealable in the traditional sense — the appropriate next step is verifying the patient was informed (ABN where applicable) and billing the patient if the determination is correct.

How to Prevent PR-60

Also Filed As

The same CARC 60 may appear with different Group Codes:

CO-60 OA-60

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.