CARC 11
Diagnosis does not support the procedure
The payer does not accept the diagnosis reported as justifying the procedure billed.
Why you actually get this
- The most specific available diagnosis was not used.
- A secondary diagnosis that would have supported the service was omitted.
- The diagnosis genuinely does not support the procedure under the payer's policy.
How to check whether it’s correct
- 01Re-read the note and confirm the diagnosis coded is the most specific one supported.
- 02Check whether a secondary diagnosis in the chart was left off the claim.
- 03Look up the payer's coverage policy for the procedure.
Usually worth appealing
One of the most recoverable denials there is. The documentation that supports the service is usually already in the chart and simply was not submitted. This is rarely a clinical disagreement.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.