Navigating Common Denial Codes in Medical Billing

Medical billing is a complex field filled with crucial specifics and details, especially when it comes to coding and insurance claims. One of the most frustrating challenges for healthcare providers is the denial of claims. Understanding the most common denial codes can help doctors and administrators avoid mistakes and improve the efficiency of claim management. Below, we detail the most frequent denial codes and offer practical tips for avoiding them.

CO 11: Diagnosis Code Does Not Match with the Procedure

This code is used when the diagnosis codes do not justify the medical necessity of the performed procedure or when the procedure codes submitted do not match the diagnosis codes. Ensure to:

 ✅Verify that each service has a corresponding diagnosis code.

 ✅Use updated and valid diagnosis codes.

 ✅Properly align procedure codes with the diagnosis codes.

CO 27: Insurance Expired

Claims can be denied if the patient’s insurance was expired at the time of service. It is crucial to:

 ✅Validate and update the patient’s insurance information regularly.

 ✅Ensure the correct policy number is used.

CO 22: Multiple Insurers Involved

This occurs when there are coordination of benefits issues and another insurer should be considered as primary. This is common in situations involving auto or work-related accidents. It’s crucial to:

 ✅Check and coordinate benefits when multiple insurers are involved.

CO 29: Late Submission of Claims

Claims must be submitted within the deadlines set by each insurer. To prevent this issue:

 ✅Establish a strict schedule for timely submission of all claims.

MA27: Missing, Invalid, or Incomplete Name or Entitlement Number on Claim

Errors such as an outdated or incorrect Medicare policy number can cause this type of denial. To avoid it:

 ✅Review and confirm all patient information before submitting the claim.

N245: Invalid or Incomplete Plan Information for Other Insurance

Missing information about secondary or tertiary insurances can lead to denials. Ensure to:

 ✅Include and verify all additional insurance information on the claim form.

MA112: Incomplete, Invalid, or Missing Group Practice Information

Discrepancies or missing provider information on the claim can be problematic. It is essential to:

 ✅Keep all provider and group practice demographics up to date and correctly linked.

N286: Missing, Invalid, or Incomplete Primary Identifier for Referring Provider

Information for the referring/ordering provider, including name and NPI, is mandatory. To prevent denials:

 ✅Ensure that all referring provider information is complete and correct on each claim.

CO 197: Authorization/Precertification Missing or Invalid

Lack of proper authorization can lead to denials. Remember to:

 ✅Obtain and verify the necessary authorization before performing any services.

CO 242: Services Rendered by Non-Participating Providers

When services are rendered by providers outside the plan’s network, claims can be denied. It is crucial to:

 ✅Confirm the provider’s participation in the network before providing services.

Understanding and efficiently managing these denial codes will not only help improve the acceptance rate of your claims but also optimize administrative workflow and ensure adequate compensation for provided services. At BilliMD, we are committed to helping you navigate these challenges with ease and efficiency.