Even the most skilled coding specialist has seen a denied claim. When a claim is denied or returned as unprocessable, the carrier should cite a "reason code." In efforts to help practices code more effectively, we at DermResources periodically monitor reason codes frequently used by various Medicare carriers/MACs. The following is a look at denial codes recently reported by the Florida carrier. These codes are universal, as are the prescribed strategies for correcting them.

Common Reasons for Denials
CO 18 – Duplicate claim. When one line item must be re-billed, re-bill only that line item. If you are unable to do this, contact your software support for instruction.

CO 11 – Procedure code is incompatible with diagnosis. Check Local Coverage Determinations to learn what ICD9 codes are acceptable for coverage of the involved CPT codes. Go online to www.cms.hhs.gov/mcd/overview.asp? from2=overview.asp to find LCD information.

CO 97 – Payment adjusted because this procedure/service is not paid separately. This denial code is used when you have not applied modifier 59 or modifier 79 when needed. If the codes billed oppose each other in the Correct Coding Initiative, and the procedures are performed on separate body sites, the 59 must be applied in order to effect payment. Modifier 79 must be added to procedures performed in a post-operative period that are unrelated to the original surgery.

CO B9 – Services are not covered because the patient is enrolled in a hospice. When a patient is enrolled in a hospice, Medicare will no longer pay for services related to the terminal illness. If treatment is for comfort measures outside the auspices of hospice care, modifier GW is used to show that the condition being treated is unrelated to the terminal illness.

CO 22 – Payment adjusted because this care may be covered by another payer per coordination of benefits. This denial indicates that the Medicare carrier has information that the patient has insurance that is primary to Medicare, such as through employment of the patient or spouse. This situation can be avoided by having the patient answer questions related to other coverage at registration. If there has been a denial, and the patient states that he/she does not have such coverage, he/she should contact the Coordination of Benefits Contractor at (800) 999-1118.

CO 24 – Payment for charges adjusted. Charges are covered under a capitation agreement or managed care plan. This claim must be submitted to the patient's HMO. Use your Medicare carrier's Interactive Voice Response (IVR) to obtain enrollment information.

CO 16 – Claim/service lacks information, which is needed for adjudication. Additional information is supplied using remittance advice. This denial could result from improper placement of NPI or lack of referring physician information or CLIA information. When the group NPI is entered in item 33a, the individual NPI should be in item 24J.

When billing for a consultation or for laboratory services, the referring provider's name must be entered in item 17 and the NPI in 17b. In the case of laboratory services in a dermatology practice, the ordering provider and performing provider are often the same. The provider's own name and NPI are entered in 17 and 17b, and the CLIA number must be entered in item 23.

CO 31 – Claim denied as patient cannot be identified as our insured. The most frequent reason for this is that either the patient's name or the Medicare number has been entered incorrectly. Employees entering patient data must understand the importance of entering the name exactly as it is on the Medicare card. The patient may be Patti Smith to her friends, but if her Medicare is in the name of Bertha P. Smith, she is Bertha P. Smith in your computer.

Likewise the ID number entered must be correct and complete, including any letters, and the date of birth must be correct and in the required format. Employees must also verify that the person is eligible for Medicare part B. Some patients have only Part A, which does not cover physician charges. If the patient has Part B it will be listed on the Medicare card, along with the date of eligibility.