CO 18
Duplicate claim/service

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

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

This denial indicates a claim has been submitted to Medicare Part B for the same service and the same date of service for the same patient (duplicate) as a claim that has already been adjudicated (processed). When partial payment has been made on a claim and the situation is one where you can correct and resubmit the charge, do not resubmit the entire claim. In order to avoid this denial, resubmit denied line(s) only.

This denial indicates that two lines on the same claim are for the same service and there is no modifier present to indicate why the same service was done twice on the same day. Append the appropriate modifier to the second service in order to avoid this denial.

This denial indicates a claim has been submitted to Medicare Part B for the same service and the same date of service for the same patient (duplicate) as a claim that is currently processing. Before sending in another claim, check the status of the previously submitted claim by calling the Interactive Voice Response unit (IVR) at 866-419-9455. For instructions, refer to the IVR Operating Guide. Please wait 10 business days before checking on your claims through the automated IVR.

CO 96
Non-covered charge(s)

(MEDICARE DOES NOT PAY FOR THESE SERVICES OR SUPPLIES.)

THE PROCEDURE CODE SUBMITTED IS A NON-COVERED MEDICARE SERVICE.

Providers use this denial in order to show that Medicare does not cover a service when billing a supplemental insurer or the beneficiary. When billing for denial for supplemental insurer, remember to use GA/GY/GZ modifiers as appropriate.

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 not compatible with the diagnosis. You may access the procedure to diagnosis look up tool to determine if the procedure code to be billed is payable under the specific diagnosis. To locate the tool on the Connecticut Medicare provider web site, click Medicare Part B from the top navigation bar, then click the link for “Proc/Dx Look-Up (Service Indication Report)” under National Medical Coverage at the bottom of the page. On the same page, you may also refer to the Final Local Coverage Determinations (LCDs) in order to determine if specific Healthcare Common Procedure Coding System (HCPCS) codes are applicable to each LCD, as well as which diagnoses are and are not considered reasonable and necessary under that LCD.

CO 96

Non-covered charge(s)

THE PROCEDURE CODE SUBMITTED IS A NON-COVERED MEDICARE SERVICE

Use GA, GY & GZ modifiers as appropriate when billing for denial for supplemental insurer

CO 97
Payment adjusted because this procedure/service is not paid separately.

(DENIED/REDUCED SERVICE/PROCEDURE NOT PAID SEPARATELY.)

(SEPARATE PAYMENT NOT MADE FOR THIS SERVICE. DO NOT BILL PATIENT.)

This denial indicates that the service billed has already been paid as part of another service billed on the same date of service. Please take note to the quarterly updates to the National Correct Coding Initiative (NCCI) edits which are available at http://www.cms.hhs.gov/NationalCorrectCodInitEd . The purpose of the NCCI edits is to ensure the most comprehensive groups of codes are billed rather than the component parts. To learn more about NCCI, check out our web-based training course on www.fcsomedicaretraining.com . All services should be submitted on the same claim to avoid fragmented billing practices.

CO 170
Expenses incurred after coverage terminated.

(CHARGES INCURRED DURING NONENTITLED PERIOD.)

This denial occurs when the patient is no longer covered under Medicare. This occurs most often when services are billed after the patient’s date of death or after the patient has disenrolled in Medicare Part B. Providers should ensure that they keep current with changes in the patient’s insurance coverage as well as double-checking dates of service prior to submitting claims in order to avoid these denials.

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.)

This denial occurs when the Medicare files show that the patient is enrolled in a Health Maintenance Organization (HMO). Providers need to verify the patient’s HMO enrollment information using the IVR and if the patient is enrolled in an HMO, the claims must be submitted to the HMO, not Medicare. Medicare is not the secondary payer for patients enrolled in an HMO. If the patient has disenrolled from the HMO, the claim can be sent to Medicare once the system has been updated to show the disenrollment.

CO 31
Claim denied as patient cannot be identified as our insured

(PATIENT'S HIC# NONENTITLED. SUBMIT A NEW CLAIM WITH VALID HIC#.)

This denial indicates that the Medicare number submitted is not valid. Providers need to ensure that a copy of the patient’s most recently issued Medicare card is in the patient’s file in order to compare that number with the one submitted. Once the correct number is determined, resubmit the claim with the correct Medicare number.

CO 140

Patient/Insured health identification number and name do not match.

(PATIENT'S HIC# NONENTITLED. SUBMIT A NEW CLAIM WITH VALID HIC#.)

Ensure that you have a copy of the patient’s most recent Medicare card in order to determine whether the patient was entitled to Medicare on the date of service

Check the patient’s entitlement dates using the IVR at (866) 419-9455. For instructions, refer to the IVR Operating Guide.

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

FACILITY ZIP CODE OR STATE CODE INVALID OR MISSING

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

DENIED-INVALID/INCORRECT ICD-9 CODE. RESUBMIT AS A NEW CLAIM

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

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

CO 16 denials can occur for a variety of reasons. In all the situations below, providers should resubmit the claim as a new claim with the proper information. For more information on proper completion of items/fields on the CMS-1500 claim form, please reference the Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) 100-04, Chapter 26 at www.cms.hhs.gov/manuals/downloads/clm104c26.pdf

CO 4
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice

(DENIED-MODIFIER INVALID/MISSING. RESUBMIT AS A NEW CLAIM.)

Providers who need help with modifiers should check out our modifier Web-based trainings on www.fcsomedicaretraining.com . Currently, we have separate courses on modifiers 24, 25, 78, 79, and 58.

CO B18
This procedure code and modifier were invalid on the date of service.

THIS CODE IS NO LONGER VALID. RESUBMIT WITH THE CORRECT CODE.

When a claim is denied for incorrect/invalid procedure codes, which includes Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes, providers should ensure that they are referencing the book for the current year. Remember, CPT and HCPCS codes are updated (added, changed, deleted) as of January 1 each year and are usually valid from then through December 31 of the same year. The grace period for procedure codes was eliminated as of January 1, 2005.