CARC 5
Procedure conflicts with the place of service
The payer does not accept this procedure as performed in the setting reported.
Why you actually get this
- The place-of-service code was defaulted rather than set for the encounter.
- A telehealth encounter was billed with an in-person place of service, or the reverse.
- The service genuinely is not covered in that setting.
How to check whether it’s correct
- 01Confirm the place-of-service code matches where care was actually delivered.
- 02For telehealth, check the payer's current expectation — these rules have changed repeatedly.
Usually worth appealing
Usually a coding correction rather than a coverage dispute. Telehealth place-of-service rules in particular have moved often enough that a process correct last year may not be now.
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.