Medicare Denials How To Handle

MEDICARE DENIAL WITH REASON CODE AND HOW TO HANDLE
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Medicare-Claim-Denial-Reason-Code-CO96-CO96-CO-96.html
What is the meaning of the CMS Medicare Claim Denial Reason

Code?: CO-16, CO/16, CO16 - Claim/service lacks information which
Your Action and How to Avoid this Kind of Denial:
This kind of rejection is very straightforward and is also easy to fix. You can
get additional information about its denial by calling your local carrier's IVR
(Interruptive Voice Response)
What to do:
1. Check Box number 32, 33 and 24J on the HCFA 1500 form -- are the
information correct?
2. Check if you the procedure code needs a modifier
3. Check if your diagnosis code requires a 4th or 5th digit
4. Check if a referring physician on box 16 is required (don't forget its NPI!)
Useful References: CPT Code Books, CMS Website (www.cms.gov),

CCI Quarterly Updates, CPT Assistant Publications, Diagnosis Code
Books
What is the meaning of the CMS Medicare Claim Denial Reason Code?:
CO-97, CO/97, CO97
Code?: CO-97, CO/97, CO97 - The benefit for this service is

included
in the payment/allowance for another service/procedure that has
already been adjudicated
Your Action and How to Avoid this Kind of Denial:
1. Check if there is a bundling issues
2. Always make sure you are up-to-date with the CCI Edits. Remember
that
an indicator "0" means you can not append a modifier on that particular
procedure code and can not be billed separately.
3. Check if the services (evaluation and management encounter and/or

other procedures) is related and within the post global surgical period;
4. It could also be that it is included during the pre-op period
Check out these Modifiers and Find out How you can appropriately (and
ethically) Utilize them:
Modifier 25
Modifier 24
Modifier 59

Books
CO109, CO/109, CO-109

Code?: CO109, CO/109, CO-109 - Claim not covered by this
payer/contractor. You must send the claim to the correct
payer/contractor.
What You Should DO:

1. Verify if maybe the patient is covered through the HMO (Health
Management Organization) with another insurance company.
Useful References: CPT Code Books, CMS Website (www.cms.gov), CCI

Quarterly Updates, CPT Assistant Publications, Diagnosis Code Books
What is the meaning of the CMS Medicare Claim Denial

Reason Code?: CO50, CO/50, CO-50 - These are non-
covered services because this is not deemed a 'medical
necessity' by the payer.
What You Should DO:
1. Check the Local Coverage Determination guidelines. You

can search the Local and National Determination Guidelines by
visiting your local Medicare contractor's website or by visiting
Useful References: CPT Code Books, CMS Website (www.

cms.gov), CCI Quarterly Updates, CPT Assistant Publications,
Diagnosis Code Books
PR/19 , PR-19, PR19

Code?: PR/19 , PR-19, PR19 - This claim is denied because the
rendered services may be related to a Workers Compensation Injury
or Illness. Please submit the claims to Workers Compensation
Carrier.
What You Should DO:
Verify it with your patient if this is really related to workers compensation

injury or illness. If it is, you must submit the claims to the workers
compensation carrier. Otherwise, you can reach Medicare's REOPENING
line and inform them that the claims is not related to workers
compensation
injury or illness.

Books
OA-22, OA22, OA/22

Code?: OA-22, OA22, OA/22 - This care may be covered by another
payer per coordination of benefits.
What You Should DO:
1. Verify if the patient is still working or the spouse is still working. If the
beneficiary or the spouse is still working, either full time or part time, they
are normally covered through their employer group.
2. Check with the patient if there is a motor vehicle or workers'

compensation claim open for the patient. If the reason for the visit is
related
to an motor vehicle or workers' compensation claim, then Medicare is a
secondary coverage for the patient.

CO58, CO/58, CO-58

Code?: CO58, CO/58, CO-58 - Payment adjusted because
treatment was deemed by the payer to have been rendered in an
inappropriate or invalid place of service.
What You Should DO:
1. Check if you billed with the correct place of service.

POS 11 Office
POS 21 Inpatient
POS 22 Outpatient
POS 24 Surgery Center

What is the meaning of the CMS Medicare Claim
Denial Reason Code?: CO96, CO/96, CO-96 - Non-
What You Should DO:
1. Check your code, is this a covered charge based on the

assigned code?. You will usually encounter this reason
code with the consult code (eg) 99241-45; 99251-99255;
99241-99245. Remember, Medicare no longer recognize
these codes as covered services effective January 1, 2010.
Useful References: CPT Code Books, CMS Website

(www.cms.gov), CCI Quarterly Updates, CPT Assistant
Publications, Diagnosis Code Books

Medicare Denials How To Handle

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MEDICARE DENIAL WITH REASON CODE AND HOW TO HANDLE

What is the meaning of the CMS Medicare Claim Denial Reason

Useful References: CPT Code Books, CMS Website (www.cms.gov),

Code?: CO-97, CO/97, CO97 - The benefit for this service is

Your Action and How to Avoid this Kind of Denial:

1. Check if there is a bundling issues

3. Check if the services (evaluation and management encounter and/or

4. It could also be that it is included during the pre-op period

Useful References: CPT Code Books, CMS Website (www.cms.gov),

What is the meaning of the CMS Medicare Claim Denial Reason

What You Should DO:

Useful References: CPT Code Books, CMS Website (www.cms.gov), CCI

What is the meaning of the CMS Medicare Claim Denial

What You Should DO:

1. Check the Local Coverage Determination guidelines. You

Useful References: CPT Code Books, CMS Website (www.

What is the meaning of the CMS Medicare Claim Denial Reason

What You Should DO:

Verify it with your patient if this is really related to workers compensation

Useful References: CPT Code Books, CMS Website (www.cms.gov),

What is the meaning of the CMS Medicare Claim Denial Reason

What You Should DO:

2. Check with the patient if there is a motor vehicle or workers'

Useful References: CPT Code Books, CMS Website (www.cms.gov), CCI

What is the meaning of the CMS Medicare Claim Denial Reason

What You Should DO:

1. Check if you billed with the correct place of service.

Useful References: CPT Code Books, CMS Website (www.cms.gov), CCI

What You Should DO:

1. Check your code, is this a covered charge based on the

Useful References: CPT Code Books, CMS Website

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