Partial denial describes a RAC denial in which the service was not reasonable or necessary but a lower level service would be, or when the service was upcoded or an incorrect code submitted which yielded a higher reimbursement.

Partial denial describes a RAC denial in which the service was not reasonable or necessary but a lower level service would be, or when the service was upcoded or an incorrect code submitted which yielded a higher reimbursement.

• A. The denial based on patient eligibility
• B. A RAC denial that occurs when the service was not reasonable or necessary but that a lower level service would be, or when the service was upcoded or an incorrect code submitted which yielded a higher reimbursement of the service
• C. The denial due to clerical error only
• D. A denial determined by CMS for not meeting coverage criteria

Answer: (B)

Partial denial reflects a RAC decision where the issue is tied to medical necessity or coding accuracy. In this situation, the service billed may have been more extensive than what was actually needed (not reasonable or necessary), or the claim was upcoded or submitted with an incorrect code that produced higher reimbursement. Because of that, part of the charge is disallowed while correctly coded portions that reflect the appropriate level of service can still be paid. This differs from denials based on patient eligibility, clerical errors alone, or not meeting coverage criteria, which address different reasons for denial and don’t center on the relation between the actual service and its coding.

Partial denial reflects a RAC decision where the issue is tied to medical necessity or coding accuracy. In this situation, the service billed may have been more extensive than what was actually needed (not reasonable or necessary), or the claim was upcoded or submitted with an incorrect code that produced higher reimbursement. Because of that, part of the charge is disallowed while correctly coded portions that reflect the appropriate level of service can still be paid. This differs from denials based on patient eligibility, clerical errors alone, or not meeting coverage criteria, which address different reasons for denial and don’t center on the relation between the actual service and its coding.