P18Denial Code (CARC)Active
P18 Denial Code - Procedure Not in Fee Schedule
Code P18 indicates that the billed procedure isn't listed in the jurisdiction's fee schedule for Property and Casualty claims. Instead, a comparable service allowance has been made, meaning the payer adjusted the charge to reflect a similar service's rate.
Who Pays: Group Code Liability
The group code for CARC P18 typically falls under CO, meaning the provider must write off the difference and cannot bill the patient for it.
Why Claims Get Code P18
- The billed procedure code is not included in the jurisdiction's fee schedule for Property and Casualty claims.
- Use of an incorrect or outdated procedure code that doesn't match the fee schedule.
- Coding errors where the service provided doesn't align with the jurisdiction's recognized codes.
- Lack of awareness about jurisdiction-specific fee schedules for Property and Casualty.
- Submitting a claim to the wrong jurisdiction.
How to Fix & Resubmit
- Verify the procedure code used on the claim against the jurisdiction's current fee schedule for Property and Casualty.
- Check if a comparable service allowance was made by the payer and ensure it aligns with the service provided.
- Correct the procedure code if an error is identified and resubmit the claim as necessary.
- Contact the payer for clarification if the adjustment does not seem appropriate or to understand the comparable service allowance applied.
- Document the findings and any payer communication for future reference.
Corrected Claim or Appeal?
For CARC P18, a corrected claim is appropriate if a coding error is found. If the payer's adjustment seems incorrect after verification, a formal appeal may be warranted.
Preventing Future P18 Denials
- Regularly update and review the jurisdiction's fee schedule for Property and Casualty claims to ensure compliance.
- Implement a check system for procedure codes before claim submission to identify non-listed codes.
- Educate coding staff about jurisdiction-specific requirements for Property and Casualty claims.
- Regularly audit claims to ensure correct jurisdictional submission and code use.