10/01/2021
What is a Coding Denial?
A denied claim is a claim that has made it through the adjudication system—it’s been received and processed by the insurance or third-party payer. However, the claim has been deemed unpayable for services received from the healthcare provider.
CO-4: The procedure code is inconsistent with the modifier used or the required modifier is missing for adjudication (the decision process). Use the appropriate modifier for that procedure. For example, some lab codes require the QW modifier.
CO-97: The payment was adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Resubmit the claim with the appropriate modifier or accept the adjustment.
OA-109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. Review coverage and resubmit the claim to the appropriate carrier.
PI-204: This service/equipment/drug is not covered under the patient’s current benefit plan. Bill the patient.
CO-50: Non-covered services that are not deemed a “medical necessity” by the payer. To avoid coding denials, when you use a CPT® code, you must also demonstrate that it is “reasonable and necessary” to diagnose or treat the patient’s medical condition. Medical necessity is based on “evidence-based clinical standards of care.” Check the diagnosis codes or bill to the patient.
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