Top 10 Claim Denials
What should you do when you get a denial?
• Do you file a new claim?
• Request an appeal?
• Top denials will be discussed
o Denial codes and descriptions
o Reason denial occurred
o How to resolve and avoid future denials
1. 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.
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 homepage
2. Denial Code CO -125, MA120
Denial message
• Payment adjusted due to billing or submission error (125)
• Missing/incomplete/invalid CLIA certification number (120)
Reason for denial
• Claim contains incomplete/or invalid CLIA certification number
How to resolve and avoid future denials
• 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.
3.Denial Code CO - 16, MA83
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
4. Denial Code CO - 16, N290
Denial Message
• Claim/service lacks information which is needed for adjudication (16)
• Missing/incomplete/invalid rendering provider identifier (290)
Reason for denial
• The claim was filed with an invalid or missing rendering NPI
How to resolve and avoid future denials
• Refile the claim with the valid rendering provider’s NPI in Item 24J of the CMS 1500 claim form
• For assistance with obtaining NPIs
o NPI Registry
• https://nppes.cms.hhs.gov
5. Denial Code CO - 16, N257
Denial message
• Claim/service lacks information which is needed for adjudication (16)
• Missing/incomplete/invalid billing provider primary identifier (257)
Reason for denial• The claim was filed with an invalid or missing NPI
How to resolve and avoid future denials
• File claims with the valid billing provider NPI
• Verify the appropriate billing provider NPI is listed in Item 33 of CMS 1500 claim form
• Billing for group – use group NPI
• Solo practitioner – use individual NPI
6. Denial Code CO - 5
Denial message
• The procedure code/bill is inconsistent with the place of service (05)
Reason for the denial• Service was rendered at a facility/location that was inappropriate or invalid
How to resolve and avoid future denials
• Verify that the procedure code/bill is consistent with the place of service
• Resubmit as a new claim with a procedure code consistent with the place of service
7. Denial Code CO -140, MA61
Denial message
• Patient/insured health identification number and name do not match (140)
• Missing/incomplete/invalid social security number or health insurance claim number (61)
Reason for denial• Claim was filed for a patient whose Medicare number does not match the SSA records and CWF
How to resolve and avoid future denials
• Review the patient’s file to locate a copy of the Medicare card. If copy has not be obtained:
o Contact the patient for the information
o Call the referring/ordering physician to obtain the information
• File a new claim with the correct name and Health Insurance Claim Number (HIC) as listed on the Medicare card
8. Denial Code CO - 96, M117
Denial message
• Non-covered charge(s) (96)
• Not covered unless submitted via electronic claim (117)
Reason for denial• Claims were received in hard copy format
How to resolve and avoid future denials
• Submit claims electronically in the HIPAA complaint 837 format
• If you must submit hard copy claims, contact EDI Technology Support Center to appeal your filing status
• EDI Technology Support – 1-866-749- 4301
9. Denial Code CO - 16, N286
Denial message
• Claim/service lacks information which is needed of adjudication (16)
• Missing/invalid/incomplete referring provider primary identifier (286)
Reason for denial• Claim was filed with a invalid or missing NPI in Item 17B of CMS 1500 Claim Form
How to resolve and avoid future denials
• Refile the claim with the valid referring provider NPI in Item 17B of the CMS 1500 Claim Form
• For NPI listing, visit
o http://www.nppes.cms.hhs.gov
10. Denial Code Co -16, N234
Denial message
• Claim/service lacks information needed for adjudication (16)
• Missing/incomplete/invalid last seen visit date (234)
Reason for denial
• Claim was not submitted with a 6-digit or 8-digit date patient was last seen by their attending physician
How to resolve and avoid future denials
• Routine foot care
o Item 19 of CMS 1500 claim form
• Include a 6-digit (mm/dd/yy) or an 8-digit (mm/dd/yyyy) date patient was last seen by his/her attending physician
• Include the NPI of the patient’s attending physician
What should you do when you get a denial?
• Do you file a new claim?
• Request an appeal?
• Top denials will be discussed
o Denial codes and descriptions
o Reason denial occurred
o How to resolve and avoid future denials
1. 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.
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 homepage
2. Denial Code CO -125, MA120
Denial message
• Payment adjusted due to billing or submission error (125)
• Missing/incomplete/invalid CLIA certification number (120)
Reason for denial
• Claim contains incomplete/or invalid CLIA certification number
How to resolve and avoid future denials
• 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.
3.Denial Code CO - 16, MA83
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
4. Denial Code CO - 16, N290
Denial Message
• Claim/service lacks information which is needed for adjudication (16)
• Missing/incomplete/invalid rendering provider identifier (290)
Reason for denial
• The claim was filed with an invalid or missing rendering NPI
How to resolve and avoid future denials
• Refile the claim with the valid rendering provider’s NPI in Item 24J of the CMS 1500 claim form
• For assistance with obtaining NPIs
o NPI Registry
• https://nppes.cms.hhs.gov
5. Denial Code CO - 16, N257
Denial message
• Claim/service lacks information which is needed for adjudication (16)
• Missing/incomplete/invalid billing provider primary identifier (257)
Reason for denial• The claim was filed with an invalid or missing NPI
How to resolve and avoid future denials
• File claims with the valid billing provider NPI
• Verify the appropriate billing provider NPI is listed in Item 33 of CMS 1500 claim form
• Billing for group – use group NPI
• Solo practitioner – use individual NPI
6. Denial Code CO - 5
Denial message
• The procedure code/bill is inconsistent with the place of service (05)
Reason for the denial• Service was rendered at a facility/location that was inappropriate or invalid
How to resolve and avoid future denials
• Verify that the procedure code/bill is consistent with the place of service
• Resubmit as a new claim with a procedure code consistent with the place of service
7. Denial Code CO -140, MA61
Denial message
• Patient/insured health identification number and name do not match (140)
• Missing/incomplete/invalid social security number or health insurance claim number (61)
Reason for denial• Claim was filed for a patient whose Medicare number does not match the SSA records and CWF
How to resolve and avoid future denials
• Review the patient’s file to locate a copy of the Medicare card. If copy has not be obtained:
o Contact the patient for the information
o Call the referring/ordering physician to obtain the information
• File a new claim with the correct name and Health Insurance Claim Number (HIC) as listed on the Medicare card
8. Denial Code CO - 96, M117
Denial message
• Non-covered charge(s) (96)
• Not covered unless submitted via electronic claim (117)
Reason for denial• Claims were received in hard copy format
How to resolve and avoid future denials
• Submit claims electronically in the HIPAA complaint 837 format
• If you must submit hard copy claims, contact EDI Technology Support Center to appeal your filing status
• EDI Technology Support – 1-866-749- 4301
9. Denial Code CO - 16, N286
Denial message
• Claim/service lacks information which is needed of adjudication (16)
• Missing/invalid/incomplete referring provider primary identifier (286)
Reason for denial• Claim was filed with a invalid or missing NPI in Item 17B of CMS 1500 Claim Form
How to resolve and avoid future denials
• Refile the claim with the valid referring provider NPI in Item 17B of the CMS 1500 Claim Form
• For NPI listing, visit
o http://www.nppes.cms.hhs.gov
10. Denial Code Co -16, N234
Denial message
• Claim/service lacks information needed for adjudication (16)
• Missing/incomplete/invalid last seen visit date (234)
Reason for denial
• Claim was not submitted with a 6-digit or 8-digit date patient was last seen by their attending physician
How to resolve and avoid future denials
• Routine foot care
o Item 19 of CMS 1500 claim form
• Include a 6-digit (mm/dd/yy) or an 8-digit (mm/dd/yyyy) date patient was last seen by his/her attending physician
• Include the NPI of the patient’s attending physician
DENIAL CODE 234 WITH REMARK N381
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