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Tuesday, May 25, 2010

Medicare denial CO 4, C0 125 , MA 120, CO 16 & MA 83

Denial code CO 4

Denial Message
• The procedure code is inconsistent with the modifier used, or a required modifier is missing (04)


Reason for Denial

  •  Claim was filed with a procedure code and modifier that did not correspond
  • Check the Modifiers used with CPT code
  • Billing with Modifier EY and check other lines ites if any does not have Modifier EY
  • UC Modifier missing on Procedure Code.
  • Invalid pickup location modifier.
  • Invalid destination modifier.
  • Modifier not authorized for claim type.
  • U Modifier is missing or invalid for particular waiver program.
  • Missing or invalid modifier
  • Invalid Procedure to modifier
  • Invalid modifier for procedure code. See provider manual, section 2 for modifier requirements.
  • Invalid modifier for transport
  • Procedure requires modifier.



How to resolve and avoid future denials

• Verify that the procedure code and modifier descriptions correspond with each other

• File claims with consistent procedure code and modifier descriptions

• Access the Modifier Lookup tool on www.PalmettoGBA.com/bsc

* EY Modifier has to go with all the CPT with EY Modifier. Resubmit if missing any.

* RESUBMIT A NEW CLAIM WITH THE REQUESTED INFORMATION. 




Denial reason code co 125 , MA 120

Denial message
• Payment adjusted due to billing or submission error (125)
• Missing/incomplete/invalid CLIA certification number (120)
PROCEDURE BILLED IS NOT AUTHORIZED PER YOUR CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) PROFICIENCY TEST


Reason for denial
• Claim contains incomplete/or invalid CLIA certification number

How to resolve and avoid future denials

* Check that the CLIA number used on the claim is certified to perform the procedure.

*Procedure requires a valid CLIA certificate number. Rebill with valid certificate number.

• Resubmit the claim using the appropriate CLIA number in Item 23 of the CMS 1500 claim form or in Loop 2300 or 2400, REF/X4, 02 for electronic claims

• Updates to the waived test under CLIA are published in the Medicare Advisory

• A complete list of tests granted waived status under CLIA is attached to CR 5913 at www.cms.hhs.gov/Transmittals/downloads/ R1477CP.pdf.


Medicare denial code co 16 MA 83

Denial message
•Claim/service lacks information which is needed for adjudication (16)
• Did not indicate whether Medicare is primary or secondary payer (83)

Reason for denial

•The MSP type was not submitted in the 2000B, SBR, 05 (Insurance Type Code) field

How to resolve the denial

• Resubmit the claim with the appropriate MSP type in the Insurance Type Code field
• For a complete list of MSP types
www.PalmettoGBA.com/bsc/resources
o Select Medicare Secondary Payer
o Electronic Claims – Valid MSP Types

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