PR-B22: Payment Adjusted Based on Diagnosis

What Does PR-B22 Mean?

PR-B22 shifts the cost to the patient when the diagnosis indicates a non-covered condition under the patient's plan. This occurs when the billed procedure is only covered for specific diagnoses and the patient's condition falls outside the covered list. The patient is responsible for the full charge because their insurance does not cover the service for the documented diagnosis.

CARC B22 is a diagnosis-driven payment adjustment. The payer reviewed the ICD-10 diagnosis code on the claim and determined it does not meet the criteria for the billed service. This could mean the diagnosis does not support medical necessity for the procedure, the diagnosis code is incorrect or insufficiently specific, or the diagnosis-procedure pairing violates the payer's Local Coverage Determination (LCD) or National Coverage Determination (NCD) policies.

Unlike coding error denials that focus on procedure codes, B22 specifically targets the diagnosis side of the equation. The procedure code may be perfectly valid, but if the supporting diagnosis does not justify the service under the payer's rules, the payment is adjusted. Common examples include billing a screening test with a diagnosis code for an established condition (which changes the payment rate), using an unspecified diagnosis when the payer requires a specific ICD-10 code to the highest level of detail, or submitting a procedure that is only covered for certain diagnoses.

B22 appears with CO when the diagnosis-procedure mismatch is a coding issue the provider must absorb. Under PR, the diagnosis may indicate a non-covered condition where the patient bears the cost. Either way, resolution starts with comparing the diagnosis code on the claim against the medical record documentation and the payer's coverage rules. If the diagnosis was coded incorrectly, a corrected claim resolves the issue. If the diagnosis is correct but the payer disagrees on medical necessity, a clinical appeal is the next step.

Common Causes

How to Resolve

Verify the diagnosis code accuracy and payer coverage rules, then resubmit with corrected coding or appeal with medical necessity documentation.

1. Verify the diagnosis code is correct Before billing the patient, confirm the ICD-10 code accurately reflects the documented condition. If a covered diagnosis applies, correct the code and resubmit to insurance.
2. Inform and bill the patient If the diagnosis is correct and non-covered, notify the patient of the denial reason and transfer the balance to patient A/R.
3. Offer payment options Provide the patient with payment options including installment plans for larger balances.

Common RARC Pairings

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

How to Prevent PR-B22

• Verify diagnosis-specific coverage before rendering services and inform patients of potential non-coverage with an ABN or financial waiver
• Use cost estimation tools to identify diagnosis-based coverage limitations at the point of scheduling

General Prevention

• Ensure diagnosis codes are specific, current, and accurately reflect the patient's documented condition at the highest level of ICD-10 specificity
• Review payer-specific LCD/NCD policies before billing to verify the diagnosis supports the procedure's medical necessity
• Implement coding edit software that flags diagnosis-procedure mismatches before claim submission
• Train coders on accurate ICD-10 code selection and the importance of diagnostic specificity
• Conduct regular coding audits to identify patterns of diagnosis-related denials

Also Filed As

The same CARC B22 may appear with different Group Codes:

Related Denial Codes