3 Common Denial Codes in Medical Billing

An American Hospital Association survey found that 89% of respondents reported an increase in their medical billing payment denials, with 51% of those respondents reporting a “significant” increase. Medical billing is a difficult enough job without claim denials interrupting your administrative workflow.

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But you should know that it is impossible to avoid claim denials altogether. It’s part of the job. Without receiving denials, how are you supposed to keep track of what is working with your billing processes and what isn’t? But what you can do is create a management plan to help reduce the rate of denials all together. And one of the most important steps in being able to do this is to familiarize yourself with some of the more common denial codes.

Here are a few denial codes and some tips on how to fix them.
When looking at common denial codes, CO 11 is one of the more prevalent ones. This code means that a claim has a diagnosis code that does not match with the procedure or services given at the appointment. Side note here: a diagnosis code is used to define the medical concern of the patient during a doctor visit.

Oftentimes you receive this denial code because there is a mistake in the coding. Like I said before, an incorrect diagnosis code is likely the culprit, so the first thing to do is to check for that. Refer to your coding team and look over the patient’s record to ensure that there is not a typo or another error.

If there is an error or an incorrect diagnosis, use this information to correct the claim and resubmit it. But if you cannot find an error, you have the option to appeal the claim. Remember that if you do decide to appeal the claim, always provide any records that back up the medical necessity of the procedure for the diagnosis.

Next is denial code CO 15. This code means that the claim you entered has the wrong authorization number for a service or a procedure. Sometimes you may need prior approvals to receive proper coverage for certain procedures or treatments for a patient. After you gain this approval, you must then enter the correct prior authorization number in block number 23. Note that this block is on the CMS-1500 form.

If you receive this denial code, that means that there is a hiccup somewhere in this process. You should address this denial code first by:
1. Reviewing the claim to see whether your team submitted the prior authorization request.
2. Recheck block number 23 for any errors.
3. If the pre-authorization information is not available, attempt to get retro-authorization for the claim.

The last code we are going to go over is CO 16, which is probably one of the most common denial codes you will come across. You will receive a CO 16 code if you submit a claim with missing information or missing/incorrect modifiers. Some other reasons for CO 16 include:
Demographic errors.
Technical errors.
Invalid Clinical Laboratory Improvement Amendments (CLIA) number
Missing social security number

To fix CO 16 claim denials, you should pay attention to any accompanying remark codes. These remark codes are there to help you further define what information is missing so you can make changes accordingly.

Again, running into claim denials is going to be inevitable. It’s not a question of whether or not health insurance companies will deny claims, but instead when and why. Treating each denial as a learning experience and becoming familiar with these more common codes will help indicate workflow issues that you can not only correct, but then prevent from happening again in the future.

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