CARC B22 Active

PR-B22: Payment Adjusted Based on Diagnosis

TL;DR

PR-B22 means the patient owes because the diagnosis does not support the procedure. Verify coding accuracy and appeal if the service was medically necessary.

Action
Collect from Patient
Who Pays
Patient
Appeal
Yes
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-B22 Mean?

When paired with Group Code PR, the patient is responsible because the diagnosis does not support coverage for the procedure. Collect from the patient after verifying the denial is correct. Appeal if the procedure was medically necessary for the diagnosis.

CARC B22 indicates the payer adjusted the payment based on the diagnosis codes submitted with the claim. The diagnosis either does not support medical necessity for the billed procedure, triggers a lower fee schedule rate, results in a different DRG assignment, or does not appear on the payer's approved diagnosis list for the service (LCD/NCD).

This is one of the most common coding-related adjustments. It frequently occurs when diagnosis codes are too generic or non-specific, when the LCD/NCD restricts coverage of the procedure to specific diagnoses, when the diagnosis-procedure combination does not establish medical necessity, or when incorrect coding causes a DRG weight reduction for inpatient claims.

The resolution path depends on whether the issue is a coding error (wrong or non-specific diagnosis) or a coverage determination (the diagnosis genuinely does not support the procedure). Coding errors can be corrected and resubmitted. Coverage determinations require a clinical appeal with documentation supporting medical necessity.

Common Causes

Cause Frequency
Service not medically necessary for diagnosis The payer determined the service is not medically necessary for the patient's diagnosis, shifting responsibility to the patient Most Common
Elective procedure not supported by diagnosis The submitted diagnosis does not support coverage for what the payer considers an elective procedure Common

How to Resolve

  1. Verify coding Confirm the diagnosis code accurately reflects the patient's condition.
  2. Appeal if medically necessary If the procedure was necessary for the diagnosis, appeal with clinical records.
  3. Collect if valid If the denial is valid, inform the patient and collect.
Appeal Guide

Appeal with clinical records showing the procedure was medically necessary for the patient's diagnosis.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-B22:

RARC Description
N130 Alert: You may need to review plan documents or guidelines. Review plan documents for diagnosis-based coverage restrictions →

How to Prevent PR-B22

Also Filed As

The same CARC B22 may appear with different Group Codes:

CO-B22 OA-B22

Related Denial Codes

PR-149 — Lifetime Benefit Maximum Reached PR-197 — Precertification/Authorization/Notification Absent PR-201 — Patient Responsibility via Set-Aside Arrangement PR-238 — Claim Spans Eligible/Ineligible Periods - Ineligible Reduction PR-247 — Deductible for Professional Service in Institutional Setting

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.cms.gov/regulations-and-guidance/guidance/manuals
  3. Codes maintained by X12. Visit x12.org for official definitions.