2007 Code Recap

2007 is coming to an end, and we have been through an entire year of denial evaluation. Let’s recap the top Medicare denials:

1. CO18 – Duplicate claim
2. OA109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
3. CO57 – Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day’s supply.
4. CO175 – Payment denied because the prescription is incomplete.
5. PR96 – Non-covered charge(s)
6. CO50 – These are non-covered services because this is not deemed a “medical necessity” by the payer.
7. CO176 – Payment denied because the prescription is not current.
8. CO16 – Claim/service lacks information which is needed for adjudication.
9. CO13 – Date of death precedes date of service.
10. CO35 – Lifetime benefit maximum has been reached.
11. PR22 – Payment adjusted because this care may be covered by another payer per coordination of benefits.

There are a number of remaining denial codes that, taken together, represent 20.4 percent of Medicare claim denials. Separately, however, none of the remaining codes represent more than 1 percent of the reasons for denial.

So, as you look back on 2007 and consider how to manage your denials, remember to evaluate why you are receiving them.

Don’t look at your denials on a patient-by-patient basis. Aggregate your denials to determine which codes are your most problematic. Once you gain that information, assess why you have received those particular denials in the past, and figure out how your team can improve and reduce them.

Denials are most likely a result of more than just the billing team. Once you determine what and where the problem(s) are, plan your attack to reduce those denials, and move into 2008 with a new attitude, one that gives you control of your cash flow. Make 2008 your year to be proactive rather than reactive in working down denials.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. She can be contacted at 419/448-5332 or [email protected].

Based on analysis of 3,680,443 claims adjudicated by the Medicare contractors between July 1, 2006, and Sept. 30, 2006, and processed for RemitDATA customers. Source: RemitDATA, 866/885-2974, www.remitdata.com.