Medical Billing Denial Codes & Reasons [Complete Guide]

Navigating the labyrinthine world of medical billing can often be likened to solving an intricate puzzle. At the heart of this puzzle are denial codes – the catalysts that can either streamline revenue cycles or throw them into disarray. With a comprehensive understanding of denial codes and cutting-edge solutions like Adonis Intelligence, healthcare providers can wield an impeccable blend of knowledge and technology to conquer challenges.

Unraveling the Mysteries of Denial Codes

Denial codes are an integral part of the medical billing process. They indicate why an insurance payer has denied reimbursement for a healthcare service. Accurate interpretation and prompt action on these codes are critical for effective revenue cycle management.

The Fabric of Denial Codes

1. CO (Contractual Obligations): Denotes contractual agreements between the provider and the insurance payer. For instance, CO 97 implies that the claim was denied because the service is included in another service or procedure already adjudicated.
2. PR (Patient Responsibility): These codes indicate that the patient is responsible for the expenses, such as co-pays or deductibles.
3. CR (Correction and Reversals): This type of code is used to handle mistakes and reversals in the billing process.

Understanding these codes and acting accordingly is vital. However, manual handling can lead to errors.

Challenges That Besiege Manual Handling of Denial Codes

Overwhelmed by Complex Codes

The sheer volume and intricacy of denial codes can be daunting. The manual handling of these codes often results in errors and inefficiencies.

Time-Consuming and Labor-Intensive

A significant amount of time and effort is required to decipher and rectify denial codes, which slows down the revenue cycle.

Lack of Real-time Insights

Manual processes lack the ability to provide real-time insights into denial trends, which is critical for proactive action

Decoding Key Billing Denial Codes and the Adonis Intelligence Advantage

In the complex world of medical billing, it's crucial to understand the denial codes and their meanings. Let's dive into some common denial codes and explore how Adonis Intelligence can be an invaluable ally in handling them with sophistication and efficiency.

CO 45 – Contractual Obligation; Charge Exceeds Fee Schedule

When you encounter the CO 45 code, it means that the billed service exceeds the fee schedule that has been agreed upon with the insurance. Adonis Intelligence comes with an underpayments detection feature which ensures that services are billed according to the contracted rates, and if there are any discrepancies, they are flagged in real-time. This prevents the CO 45 denials and helps in optimizing the revenue cycle.

CO 97 – Service Already Adjudicated or Claim Lacks Information for Adjudication

This denial code indicates that the claim lacks the necessary information for adjudication or has already been evaluated. The sophisticated features of Adonis Intelligence come into play here. Its custom scrubber edits and comprehensive reporting functionality ensure claims are submitted with all required information, thus minimizing such denials. Adonis Intelligence also helps in avoiding duplicate claims, which can trigger CO 97.

CO 50 – Lack of Prior Authorization

The denial code CO 50 indicates that the service was rendered without obtaining the required prior authorization. This is where Adonis Intelligence’s real-time alerts and tracking features enable providers to proactively monitor and obtain necessary authorizations, effectively reducing such denials.

PR 1 – Deductible Amount

When you see a PR 1 code, it implies that the patient is responsible for the deductible amount. Adonis Intelligence’s comprehensive reporting and real-time tracking help in keeping an eye on patients’ deductibles. It aids in educating patients beforehand regarding their financial responsibilities, ensuring that the revenue cycle remains uninterrupted by such denials.

PR 204 – Service/Equipment/Drug is Not Covered Under Patient’s Plan

This denial code is used when the service, equipment, or drug is not covered under the patient's current insurance plan. Having an insurance eligibility verification feature, healthcare providers can determine patient coverage before services are rendered. This proactive approach helps in reducing PR 204 denials.

CO 122 – Non-Covered, Charge Exceeding Fee Schedule/Maximum Allowed

CO 122 is used when charges have exceeded the maximum amount allowed under the patient’s health plan. 

CO 167 – Diagnosis Not Covered

The CO 167 denial code is used to reject claims that don’t fall within the coverage area of the insurance provider. 

PR 227 – Information Requested for the Calculation of Patient's Liability

When additional information is needed to calculate patient liability, the PR 227 denial code is used. Adonis Intelligence provides real-time alerts and equips the billing team to provide necessary information timely.

CO-11 Code – Duplicate Claim 

This code implies that the claim seems to be a duplicate of one already submitted. Adonis Intelligence’s analytics and tracking ensure that each claim is unique, minimizing such denials. If a duplicate arises, it can swiftly identify the root cause.

CO-22 Code – This Care May Be Covered By Another Payer Per Coordination Of Benefits 

When you receive this code, it indicates that another insurer might be responsible for covering the claim. 

CO-29 Code – The Time Limit For Filing Has Expired 

This code is used when the claim is submitted after the permitted time frame. Adonis Intelligence’s real-time alerts and scheduling ensure timely submission of claims, thus preventing such denials.

OA-23 Code – Payment Adjusted Because Charges Have Been Paid By Another Payer 

This signifies that the charge has already been paid by another insurer. 

PR-22 Code – This Care May Be Covered By Another Payer Per Coordination Of Benefits 

Similar to CO-22, Adonis Intelligence ensures claims are directed to the correct insurer, thereby minimizing misdirection and confusion.

CO-1 Code – Maximum Benefit Met 

When this code pops up, it means the patient's maximum benefit for a particular service or time frame has been reached. 

CO-104 Code – Processed According To Contractual Agreement/ Legislation 

Indicates a legislative or contractual agreement adjustment. 

CO-107 Code – Claim/Service Denied Because The Related Or Qualifying Service/Claim Was Denied Or Unpaid 

This code implies a foundational service or claim was denied, leading to subsequent denials. Adonis Intelligence's integrated approach can help identify such foundational issues, ensuring they are addressed promptly.

CO-15 Code – The Authorization Number Is Missing, Invalid, Or Does Not Apply To The Billed Services Or Provider 

It's crucial to have accurate authorization numbers. Adonis Intelligence’s validation checks ensure that the right numbers are attached to the correct claims, preventing such errors.

CO-222 Code – Service Denied Based On Utilization Review 

When services are deemed unnecessary or excessive, this code is used. 

CO-23 Code – Not Covered Due To Exclusions 

This code pops up when certain services are excluded from the patient's plan. Adonis Intelligence’s eligibility verification checks in advance to see if certain services are excluded, allowing providers to communicate this to patients before services are rendered.

CO-242 Code – Service Is Not Considered Medically Necessary 

It’s used when the provided service is deemed unnecessary medically. 

CO-26 Code – Expenses Were Incurred After Coverage Terminated 

When services are rendered after a patient's coverage has ended, this code is used.

CO-27 Code – Expenses Were Incurred Before Coverage Began 

Opposite to CO-26, this indicates services rendered before insurance coverage started. Adonis Intelligence can help providers confirm insurance start dates before services are rendered, reducing such denials.

CO-39 Code – Services Denied At The Time Authorization/Precertification Was Requested 

This code means services were denied during the authorization request phase. With Adonis Intelligence, providers get real-time alerts about authorization status, allowing for adjustments or alternative care planning.

CO-4 Code – Procedure Code Is Inconsistent With The Modifier Used 

This code arises due to a mismatch between the procedure code and the modifier. 

CO-5 Code – Procedure Code/Bill Type Is Inconsistent With The Place Of Service 

Similar to CO-4, but this code refers to mismatches between the procedure and the location of service. 

CO-55 Code – Procedure/Treatment/Diagnosis Is Deemed Experimental Or Investigational When a procedure is considered experimental, this code is used. 

CO-59 Code – Only One Visit/Day Is Covered 

This code indicates that multiple services on the same day exceed coverage limits. Adonis Intelligence’s analytics can help providers understand insurance visit limitations, ensuring billing aligns with coverage restrictions.

CO-6 Code – Patient Is Not The Primary Beneficiary 

Used when the billed patient isn't the primary beneficiary of the insurance policy. 

CO-8 Code – The Procedure Code Is Inconsistent With The Provider Type 

This code pops up when there's a mismatch between the procedure and the provider’s specialty or type. 

CO-9 Code – The Diagnosis Is Inconsistent With The Patient’s Gender 

Used when a diagnosis doesn't align with a patient’s gender. 

OA-1 Code – Claim Denied As It Lacks Detail Information 

This code arises when the claim lacks essential details. Adonis Intelligence’s robust claim builder ensures that all required fields are populated with necessary details, minimizing incomplete claim submissions.

OA-22 Code – Payment Adjusted Due To A Refund To The Patient 

This signifies an adjustment because of a refund given to the patient. 

OA-27 Code – Expenses Incurred After Pre-certification Authorization Denial 

When services are rendered after pre-certification has been denied, this code appears. Adonis Intelligence's real-time authorization alerts allow providers to be immediately aware of denials, preventing unauthorized services.

PI-11 Code – Invalid Diagnosis Code 

This code emerges when a submitted diagnosis code is invalid. 

PI-16 Code – Date Of Service Invalid 

Used when the provided service date is incorrect. Adonis Intelligence’s claims system double-checks dates of service against patient records, reducing errors in date entry.

PI-18 Code – Duplicate Claim/Service 

Similar to CO-11, this implies the claim seems to be a duplicate. Adonis uses intelligent tracking to ensure that every claim is unique and highlights potential duplicates before they're submitted.

PI-22 Code – Resubmission Of Claim Denied 

This code indicates that a previously denied claim has been resubmitted and denied again. 

PI-252 Code – Service Not Paid, Patient Is Not An Enrollee Of The Plan 

This denial implies the patient isn't enrolled in the particular insurance plan billed. Adonis Intelligence's instant insurance eligibility verification ensures services are only provided and billed when the patient is an enrollee.

PI-27 Code – Expenses Incurred Prior To Issue Date 

When services are rendered before the insurance policy's issue date, this code emerges. Adonis Intelligence cross-checks service dates against policy start dates, preventing such billing issues.

PI-29 Code – Service Already Paid Under Different Procedure Code 

This code is used when a service that's already been paid for is billed under a different code. 

PI-4 Code – Procedure Code Invalid 

When an incorrect or outdated procedure code is used, this code appears. 

PI-45 Code – Service Not Covered 

This code signifies a service that isn't covered under the patient's current plan. Adonis Intelligence’s eligibility checks help in pre-determining service coverage and alerting providers beforehand.

PI-59 Code – Invalid Provider Agreement/No Provider Rate On File 

Used when there’s no provider rate agreement in place or the one on file is invalid. 

PR-167 Code – This (These) Diagnosis(es) Is (Are) Not Covered 

This code appears when certain diagnoses aren't covered by the patient’s plan. Adonis Intelligence facilitates contact with insurance to determine which diagnoses aren’t covered, allowing providers to make informed decisions.

PR-2 Code – Coinsurance Amount 

This code means the patient is responsible for a certain percentage of the cost. 

PR-23 Code – Payment Adjusted Due To A Lack Of Certification/Authorization 

This signifies that services were rendered without necessary authorization. Adonis Intelligence's real-time alerts help providers obtain required authorizations, reducing denials.

PR-242 Code – Service Not In Accordance With Provider Agreement 

When services are provided outside the terms of the provider agreement, this code emerges. 

PR-27 Code – Expenses Incurred After Issue Date When services are billed for a date after the termination of the policy, this code is triggered. 

PR-3 Code – Copayment Amount This code signals that the patient is responsible for a fixed copayment amount. 

PR-40 Code – Charges Do Not Meet Qualifications For Emergent/Urgent Care This denial suggests the billed service doesn't qualify as emergent or urgent. 

PR-55 Code – Invalid Procedure Code/Modifier Used Much like the PI-4 code, this code indicates a procedure or modifier inconsistency.

PR-59 Code – Charges Are Adjusted Based On Multiple Surgery Guidelines Or Concurrent Care Rules 

Used when multiple surgeries or concurrent care lead to an adjustment in the billed amount. 

CO-15 Code – The Authorization Number Is Missing, Invalid, Or Doesn't Apply To The Billed Services Or Provider 

This denial emerges when there's an issue with the authorization number. Adonis Intelligence’s authorization tracker ensures valid numbers are applied to the correct services and providers.

CO-222 Code – Service Is Missing Documentation Or Has Not Been Deemed Medically Necessary By The Medical Review Department 

This code is triggered when there's a lack of supporting documentation or a challenge in medical necessity. 

CO-1 Code – Maximum Benefit Amount For This Time Period Or Occurrence Has Been Reached 

When the maximum allowable benefit is exhausted, this denial code appears. 

CO-104 Code – The Service Was Associated With A Preventative/Welfare Examination 

If a service is linked to a preventative or welfare check, this code is used. 

CO-107 Code – The Related Or Qualifying Claim/Service Was Not Identified On The Claim 

This code signifies that a related service that qualifies the patient for the current service wasn't indicated. 

OA-22 Code – Overpayment Adjustment

Signifies an adjustment because of an overpayment. Adonis Intelligence can keep track of all past payments, ensuring they align with any billing adjustments.

OA-27 Code – Expenses Incurred During A Waiting Period 

This code indicates services were rendered during a policy waiting period. 

PI-16 Code – The Date Of Death Precedes The Date Of Service 

This appears when services are billed after the reported date of death. 

PI-45 Code – Fee Exceeds Contracted Rate 

When the billed amount surpasses the contractually agreed rate, this code is used. 

CO-23 Code – The Procedure/Service Is Inconsistent With The Modality 

This denial code suggests that the billed service or procedure doesn't match the provided modality.

CO-242 Code – Service Not According To Agreement/Not Medically Necessary 

This code indicates the service doesn't adhere to the contractual agreement or is deemed medically unnecessary. 

CO-26 Code – Expenses Incurred Prior To Coverage 

When services are rendered before the start of a policy, this code is triggered. 

CO-27 Code – Expenses Incurred After Coverage Ended 

This is the opposite of the CO-26, where services are billed after a policy’s termination. 

CO-39 Code – Services Denied At The Time Authorization/Pre-certification Was Requested 

When services are rendered despite an authorization/pre-certification denial, this code appears. Adonis Intelligence’s real-time authorization features notify providers of any denials, thus preventing unauthorized services.

CO-4 Code – Procedure Code Is Inconsistent With The Modality 

Similar to CO-23, this denial suggests a mismatch between the procedure code and modality. 

CO-5 Code – Procedure/Service Was Partially Or Fully Furnished By Another Provider 

This denial appears when a procedure or service was also provided by another healthcare entity. 

CO-55 Code – Procedure/Service Was Paid Previously Under Another Claim 

Used when a service or procedure has already been paid under a different claim. Adonis Intelligence’s duplicate detection prevents such billing errors.

CO-59 Code – Procedure/Service Was Not Deemed Clinically Appropriate 

This code implies that the provided service/procedure was not deemed clinically appropriate. 

CO-6 Code – Patient Has Not Met The Required Waiting Period 

This denial appears when services are rendered during a mandated waiting period. 

CO-8 Code – Procedure/Service Is Not Covered 

This code indicates a service isn’t covered by the patient’s plan. Adonis Intelligence’s eligibility verification helps in pre-determining service coverage.

CO-9 Code – The Diagnosis Is Inconsistent With The Procedure 

When a diagnosis doesn't align with the billed procedure, this code appears. 

OA-1 Code – Claim Denied As Duplicate This is another code for duplicate claims. Adonis Intelligence tracks all claims and prevents any duplicates from being filed.

PR-167 Code – Lack Of Referral 

This code indicates services were rendered without the necessary referral. 

PR-55 Code – Incorrect Procedure Or Diagnosis Code Used 

Used when there’s an error in either the procedure or diagnosis code. Adonis Intelligence’s coding validation ensures the use of correct and updated codes.

Adonis Intelligence: The Ultimate Shield against Denial Codes

Navigating the labyrinth of denial codes requires a powerful and intuitive solution. Adonis Intelligence offers a modern billing platform that’s designed to tackle the challenges of medical billing head-on.

With its actionable insights, real-time alerts, comprehensive reporting, and customizable features, Adonis Intelligence empowers healthcare providers to take control of their revenue cycle management.

Adonis Intelligence: The Vanguard of Revenue Cycle Management

Adonis Intelligence presents an avant-garde solution designed to turn the tide in favor of healthcare providers. With its potent combination of innovation and usability, it is a harbinger of transformation in revenue cycle management.

Modern Billing Platform

Adonis Intelligence transcends the confines of antiquated systems with a modern billing platform that boasts comprehensive reporting functionality. This empowers providers to accurately track and manage denial codes, ensuring the sanctity of revenue cycles.

Actionable Insights

Adonis Intelligence is not just about raw data; it is about actionable insights that drive decision-making. It helps to swiftly identify issues related to denial codes and rectify them, minimizing the time spent on analysis.

Navigating the Sea of Denial Codes

Real-time insights and alerts on denial codes ensure that providers can quickly react, preventing revenue leakage. Adonis Intelligence is an adept navigator in the treacherous seas of denial codes.

Executive-Level KPIs

Adonis Intelligence goes beyond the billing process and offers executive-level KPIs, enabling decision-makers to have a clear picture of their organization’s financial health.

Underpayments Detection

Underpayments are a bane for healthcare providers. Adonis Intelligence’s underpayments detection feature systematically compares the contracted rate for a service against the actual amount paid, flagging discrepancies and ensuring fair reimbursement.

Customization and Advanced Reporting

Customizing the billing process is a breeze with Adonis Intelligence. It allows for custom scrubber edits, ensuring accuracy and efficiency. Its advanced reporting capabilities provide immediate insights into key metrics, and the flexibility to create custom reports.

Revolutionizing Denial Management with Adonis Intelligence

Adonis Intelligence heralds a new era in denial management and revenue cycle management for healthcare providers. Its bevy of features, including real-time insights, underpayment detection, and extensive reporting functionality, all contribute to optimizing the handling of denial codes and safeguarding revenue.

Empowered with Adonis Intelligence, healthcare providers can cast aside the shackles of manual inefficiencies, ensure fair reimbursement, and concentrate on what matters the most – delivering exemplary care to their patients.

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