Adjustment Codes Directory

Deductible Amount

Coinsurance Amount

Co-payment Amount

The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

Charges are covered under a capitation agreement/managed care plan.

Prompt-pay discount.

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Adjusted for failure to obtain second surgical opinion

Blood Deductible.

Day outlier amount.

Cost outlier - Adjustment to compensate for additional costs.