PR — Patient responsibility — this one goes on the patient statement.
So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
The same code, a different prefix. 119 also arrives as CO 119. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says CO 119, read that page instead.
Usually lost. Recoverable only with unusual evidence. Triage by dollar value.
In the order we see it.
The patient has reached the benefit maximum for the period.
For therapy, the annual threshold was reached without a KX modifier.
Check for a KX modifier or a medical-necessity exception before writing it off.
The documentation, not the argument.
A KX modifier where continued therapy is medically necessary and documented.
Documentation supporting a medical-necessity exception.
The common mistake. Do not write this off before checking whether a KX modifier or an exception applies. On therapy claims that is the most common recoverable version of this denial.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound