Case Study 1
Charlotte visited her provider for a cough, congestion, and a sinus-type headache. The provider assigned the diagnosis code J01.90 (Acute Sinusitis) for the entire claim. The visit was coded with two procedure codes. The first one was level 3 E/M, 99213 modifier 25 and the second was a B12 injection J3420, due to Charlotte’s pernicious anemia. Charlotte was given the injection on this day, so she did not have to come back in for her regularly scheduled appointment, which was in only two days. The claim was created and submitted to the insurance company the next day.
When the remittance advice was received, office visit 99213 was paid, but the B12 injection was denied. The denial was coded as follows: Claim Adjustment Group Code (CAGC) CO and Claim Adjustment Reason Code (CARC) 50.
Respond to the following in approximately 175–350 words total:
1. What is CAGC CO?

2. What is CARC 50?

3. As the medical biller/coder, what would be your next steps? Why might the B12 injection have been denied? If necessary, how would you correct the claim?