PR-9: Diagnosis Inconsistent with Patient Age

What Does PR-9 Mean?

With PR (Patient Responsibility), the CARC 9 adjustment for diagnosis inconsistent with patient age 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 9 appears on a remittance when the payer identifies an issue related to diagnosis inconsistent with patient age. This is a technical billing or coding problem that must be corrected before the claim can be processed for payment. The denial indicates the claim data did not meet the payer's adjudication requirements.

Common scenarios that trigger this adjustment include: patient's DOB is wrong in the system, causing age to be calculated incorrectly for diagnosis validation; Diagnosis code has age restrictions that do not match the patient's actual age (e.g., pediatric condition coded for adult); Coder selected an ICD-10 code with age specificity that does not match the patient. The group code paired with CARC 9 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-9 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.

How to Prevent PR-9

• Verify patient benefits and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively

Also Filed As

The same CARC 9 may appear with different Group Codes:

Related Denial Codes