diagnosis inconsistent denial - CO 11

CO 11  The diagnosis is inconsistent with the procedure. 

 Solution:

This denial indicates the procedure code billed is incompatible with the diagnosis.

• Before billing a claim, you may access the Procedure to Diagnosis look up/ Services Indication Report  to determine if the procedure code to be billed is payable under the specific diagnosis.

• You may also refer to “ Local Coverage Determinations” for a list of procedure codes, relating to the services addressed in the LCD, and the diagnoses for which a service is/is not considered medically reasonable and necessary.

Tips to correct the denied claim :

If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• Do not resubmit an entire claim when partial payment is made; correct and resubmit denied lines only.


0178 Invalid Diagnosis Code 

The primary diagnosis is not valid. Please verify that the diagnosis code is valid and is in the correct format.

0370 Wrong Procedure Code Billed 

Check your claim to verify that the correct/valid procedure code was billed, if you feel the code is correct call the Provider Helpline to verify the code billed


0110 Diagnosis Code Does Not Agree with Age

The diagnosis given is not compatible with the enrollee's age.