The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Group code
CO, PI or PR
Category
Coding
Risk level
High
Appealable
Yes
Common RARC pairings
RARCs (Remittance Advice Remark Codes) provide the specific reason detail alongside CARC 11 on the 835 electronic remittance. These are the RARCs seen most often with this CARC.
| RARC | Meaning |
|---|---|
| M51 | Missing/incomplete/invalid procedure code(s). |
| M64 | Missing/incomplete/invalid other diagnosis. |
| M76 | Missing/incomplete/invalid diagnosis or condition. |
| MA63 | Missing/incomplete/invalid principal diagnosis. |
| MA130 | Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. |
| N115 | This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. |
| N386 | This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. Visit CMS.gov and search for Medicare Coverage Database to find a copy of the policy. |
| N657 | This should be billed with the appropriate code for these services. |
See the full resolution workflow for CARC 11
Members of the EDI-Code Intelligence Lab get the step-by-step rework path, appeal language, root-cause drivers, and prevention checklist for every CARC and RARC pairing, plus payer-specific quirks.
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