N204Remark Code (RARC)Active
N204 Remark Code - Services Under Review
The N204 remark code indicates that the payer is reviewing services to determine if they are related to a pre-existing condition. This requires the provider to submit medical records covering the prior 12 months to support the claim.
How It Relates to the Denial
The N204 remark typically accompanies a Claim Adjustment Reason Code that indicates a denial or adjustment due to a pre-existing condition review. Together, they signal that the payer needs further documentation before making a final decision on the claim.
Common Scenarios
1A provider submits a claim for a surgical procedure, but the remittance response includes a denial with a reason code related to a pre-existing condition.
→ The N204 remark suggests that the payer is questioning whether the procedure is connected to an existing health issue and requires medical records for the last year to clarify.
2A claim for physical therapy services is denied, and the remittance includes a reason code for adjustment due to a pre-existing condition review.
→ The presence of the N204 remark indicates the payer's need for medical documentation from the previous 12 months to evaluate the relationship between the patient's condition and the services billed.
3A claim for diagnostic imaging is returned with a denial stating it is under review for a possible pre-existing condition, accompanied by the N204 remark.
→ This remark indicates that the payer is considering whether the imaging services relate to a previously existing condition and is requesting supporting medical records.
What to Do
- Gather the patient's medical records for the last 12 months.
- Submit the requested documentation to the payer to support the claim.
- Ensure the records clearly indicate the patient's condition and treatment history.
What to Check
- Review the initial claim submission for completeness and accuracy.
- Check the accompanying Claim Adjustment Reason Code for specifics on the denial.
- Verify the patient's medical history to ensure relevant records are included.