Any busy federally qualified health center (FQHC) will frequently encounter the most common denial codes in medical billing. Denial codes show precisely why the payment source rejected reimbursement.
How does your organization handle denials? Each denial is an opportunity to follow up and secure approval. Addressing them promptly ensures you have the best odds of claiming maximum revenue.
Table of Contents
- What Are the Most Common Denial Codes in Medical Billing?
- CO-4 Missing Medical Modifier
- CO-11 Coding Error in Diagnostic Code
- CO-15 Missing or Invalid Authorization Number
- CO-16 Error or Lack of Information
- CO-18 Duplicate Claim or Duplicate Service
- CO-22 Coordination of Benefits Error
- CO-27 Insurance or Coverage Expired
- CO-29 Time Limit Expired
- CO-45 Excessive Charges
- CO-50 Service Is Not Medically Necessary
- CO-97 Service Already Adjudicated
- CO-167 Diagnosis Not Covered
- Who Uses Denial Codes in Medical Billing?
- Are Denial Codes Final? Can You Still Collect the Payment?
What Are the Most Common Denial Codes in Medical Billing?
Up to 49% of claims are routinely denied for common reasons. To help you identify these reasons and adapt to coding problems, we’ve compiled a list of the most common denial codes in medical billing. Here are the most important codes to know.
CO-4 Missing Medical Modifier
This code indicates the submitted procedure code is inconsistent with the modifier. A modifier shows specific information tied to the provided procedure. The most common issues are a mismatch between the code and the modifier or a modifier that is missing entirely.
CO-11 Coding Error in Diagnostic Code
A diagnostic code error suggests you have an incorrect code for the patient’s diagnosis or it is not considered pertinent to the services provided.
CO-15 Missing or Invalid Authorization Number
Most coverage providers require authorization for certain services. This code indicates no prior clearance was given as required or the authorization number is missing from the data.
CO-16 Error or Lack of Information
This is a broadly applied error for a lack of information in the claim. There may be a keystroke error or it simply lacks enough information to process appropriately.
CO-18 Duplicate Claim or Duplicate Service
Payment sources frown on duplication and won’t approve multiple requests related to the same claim. A CO-18 denial code indicates a need to check the service or claim for a previous submission.
CO-22 Coordination of Benefits Error
The coordination of benefits error typically arises when the payment source believes the service is, or should be, covered by another source. These denial codes indicate an investigation is needed to understand the full scope of the patient’s care and coverage.
CO-27 Insurance or Coverage Expired
All forms of insurance and coverage will expire for certain reasons. The patient may become ineligible or the program’s requirements may have changed. Prevent this denial code by pre-verifying coverage before the patient attends their appointment.
CO-29 Time Limit Expired
Did you miss the claim timeframe? This code indicates the time limit has expired and the claim will not be paid. This sometimes occurs when an FQHC is overwhelmed with a slow revenue cycle and can’t process claims quickly enough.
CO-45 Excessive Charges
The excessive charges code commonly arises when charges for a patient’s service rise above the contracted amount. Payment sources like Medicare, as well as private insurance companies, have strict limits for coverage levels.
Check your fee schedules. Look closely at the explanation accompanying the CO-45 code, which may say something like, “exceeds maximum permitted amount.”
CO-50 Service Is Not Medically Necessary
Coverage providers may determine that the service is not considered medically necessary. This is typically based on their definition of reasonable and necessary care for the patient’s diagnosis. Medical providers may dispute this definition by providing additional evidence or explanation.
CO-97 Service Already Adjudicated
When CO-97 is given as a denial code, it often means the service was already covered in a bundled service or by a previous claim. Therefore, the payment source considers the claim previously adjudicated and will not address it further.
CO-167 Diagnosis Not Covered
This code shows the coverage provider does not cover the indicated service. Look closely at the patient’s history including which services your clinic provided and whether the proper diagnostic codes are in place.
Who Uses Denial Codes in Medical Billing?
Denial codes are used in electronic health records (EHRs) and are the nationwide standard in U.S. healthcare. Although the average patient may be unaware of denial codes associated with their care, these codes are extremely important for the providers and payment sources handling their coverage.
Government payment sources like Medicare and Medicaid provide denial codes when claims are rejected or denied. Insurance companies use these codes too, although most FQHCs have a high proportion of patients using Medicare and Medicaid.
Healthcare providers use denial codes to understand why claims haven’t been paid and address remaining issues. Your associates may discover claims have been denied due to simple things, like missing information, or more complex reasons, like a lack of compelling evidence that the service should be covered.
Are Denial Codes Final? Can You Still Collect the Payment?
Denial codes don’t necessarily indicate a final decision. You may be able to submit additional information or make a correction and appeal the decision.
Here are some tips for improving your approved claims rate and ensuring denials result in revenue.
Work Quickly
Stay ahead of denials by working proactively on verification. Check denials daily and determine the reasons behind them. Never allow the final deadline to approach before acting on denial codes and other information your clinic receives from payment sources.
Update Coding Knowledge
Work with your associates to provide the training and guidance they need to handle your billing skillfully. Stay ahead of coding changes and follow industry best practices.
Keep Claims Clean
Maintain good data hygiene, which involves checking claims for extraneous, erroneous, and missing data. Prevent any duplication and inaccuracies that will create more work later.
Use Technology and Automation
Automation helps medical practices streamline and smooth out coding and billing processes. Automate as many tasks as possible while empowering someone to oversee the process for potential issues.
Work with a Billing Partner
It’s challenging to stay ahead of the latest billing and coding trends. Work with a trusted billing partner to refine your strategy, capture every dollar, and keep the focus on patient care.
To learn more about adapting to denial codes in medical billing, turn to Altruis. We’ll help you improve your medical coding and move more claims to successful resolutions.
