CO18
Duplicate claim/service

(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)

(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)

THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED.

CO 11
The diagnosis is inconsistent with the procedure. (THIS PROCEDURE/ITEM NOT PAYABLE FOR THE DX AS REPORTED (LMRP))

This denial indicates that the procedure code billed is incompatible with the diagnosis. You may access the Procedure to Diagnosis Look-Up/Service Indication Tool located at http://www.cms.hhs.gov/mcd/serviceindication_criteria.asp?from2=serviceindication_criteria.asp& to determine if the procedure code to be billed is payable under the specific diagnosis. You may also refer to “Final LCDs” for a list of HCPCS codes that spell out which services the LCD applies to, the diagnosis for which a service is covered, and the diagnosis for which the service is not considered reasonable and necessary.

CO 170
This payment is adjusted when performed/billed by this type of provider. (THIS SERVICE BY A CHIROPRACTOR IS NOT COVERED BY MEDICARE.)

Access the Internet-Only Manual (IOM) on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov . Publication 100-02, Chapter 15, Section 30.5 gives guidelines pertaining to chiropractor services.

CO 97
Payment adjusted because this procedure/service is not paid separately (DENIED/REDUCED SERVICE/PROCEDURE NOT PAID SEPARATELY.)

This denial indicates that the services billed have already been paid as part of another service billed on the same date of service. Please make note of the quarterly updates to the Correct Coding Initiative (CCI) edits which are available at http://www.cms.hhs.gov/NationalCorrectcodInitED/ .

The purpose of the CCI edits is to ensure that the most comprehensive groups of codes are billed, rather than the component parts.

CO 16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice

DENIED-MEDICAL RECORDS NOT PROVIDED. DO NOT BILL PATIENT.

When the medical review department issues an Additional Documentation Request (ADR) and no response is received within 45 days of the date of the request the medical review department will deny the services as not reasonable and necessary.

CO 96
Non-covered charge(s) (THE PROCEDURE CODE SUBMITTED IS A NON-COVERED MEDICARE SERVICE.)

To verify if services are covered/non-covered by Medicare, there are multiple resources that providers can consult:

CO B9

Services are not covered because the patient is enrolled in a hospice.

(THESE SERVICES ARE DENIED BECAUSE THE PATIENT IS IN A HOSPICE)

There are specific guidelines pertaining to Medicare hospice benefits. Certain Medicare coverage does not apply to a beneficiary that is enrolled in a hospice program. This link will produce a document titled “Medicare Hospice Benefits”, which details the guidelines applying to hospice cases: http://www.hospiceelpaso.org/files/cms_medicare.pdf

To determine if a patient is enrolled in a hospice program, contact the Interactive Voice Response Unit (IVR), from which the following data pertaining to the beneficiary can be obtained:

Certain modifiers apply when the services/providers are not related to hospice:

GV: Attending physician not employed or paid under agreement by the patient’s hospice provider

GW: Services not related to the hospice patient’s terminal condition

CO 22

Payment adjusted because this care may be covered by another payer per coordination of benefits.

(CLAIM MUST BE SENT TO EGHP FIRST.)

When this denial is received, it indicates Medicare has information that the patient has another insurance primary to Medicare (called Medicare Secondary Payer, or MSP). Submit the claim to the primary payer; once it is processed, a claim can be submitted to Medicare for possible secondary payment.

If the provider has information the MSP file is incorrect, the beneficiary and/or the provider will need to contact the Coordination of Benefits Contractor (COBC) at 1-800-999-1118 (Monday - Friday from 8:00 a.m. to 8:00 p.m. Eastern Time) to have the file updated. Once the file is updated, the claim can be submitted to Medicare as primary.

To learn more about MSP, check out our Web-based training course on www.fcsomedicaretraining.com .

CO 24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan (THIS CLAIM MUST BE SUBMITTED TO THE PATIENT'S HMO.)

CO 31
Claim denied as patient cannot be identified as our insured (PATIENT'S HIC# NONENTITLED. SUBMIT A NEW CLAIM WITH VALID HIC#.)

CO 16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice

(DENIED-RENDERING PHYSICIAN #INVALID/MISSING. SUBMIT A NEW CLAIM)

(REFERRING NAME AND UPIN REQUIRED. RESUBMIT AS A NEW CLAIM.)

(DENIED-CLIA NUMBER INVALID OR MISSING.)

DATES FILED ON CMS-1500 ARE NOT CONSISTENT 6 DIGIT VS 8 DIGIT.

(DENIED-FIELD 11 OF HCFA [CMS] 1500 MUST BE COMPLETED)

FACILITY ZIP CODE OR STATE CODE INVALID OR MISSING.

CO B18
Payment adjusted because this procedure code and modifier were invalid on the date of service. DOCTOR'S SPECIALTY NOT APPROVED TO PRESCRIBE THIS EQUIPMENT.

This occurs when providers are using outdated procedure codes or using the wrong modifiers with a particular procedure code.