Top 10 Claim Denial Codes [+ Reasons and Strategies to Address Them]
Dealing with healthcare billing and insurance claims is a complex task, especially with frequent claim denials that disrupt healthcare providers’ revenue cycle flow. These denials are not just financial hurdles; they also demand a lot of resources to fix.
Knowing the reasons behind the denials and how to address them can help reduce mistakes and speed up payment processes.
Let’s explore the top 10 claim denial codes, their reasons, and strategies to reduce their denial rate.
| Denial Code | Reason |
| CO-11 | The diagnosis code doesn’t match the procedure or is not specific enough to justify the treatment. |
| CO-15 | Service was provided without necessary authorization or pre-certification. |
| CO-16 | The claim needs more information for payment adjudication. |
| CO-18 | The claim is submitted more than once for the same service and date. |
| CO-29 | Claim submission exceeds the insurer’s time limit for filing. |
| CO-204 | Service/equipment/drug not covered under patient’s benefit plan. |
| CO-253 | Reduction in payment due to federal budget sequestration. |
| CO-167 | The patient has reached the lifetime benefit maximum for the service. |
| CO-22 | Another insurer may cover the care per coordination of benefits. |
| CO-97 | The service is included in the payment for another adjudicated service. |
Reasons for the Most Common Denial Codes in Medical Billing and How to Address Them
1. Denial Code 11 (CO-11)
Diagnosis Not Specific Reason.
The diagnosis code doesn’t match the procedure or is not specific enough to justify the treatment.
How to Address It:
To avoid CO-11 denials, ensure that documentation supports the most specific diagnosis code available. Continuous staff training on the latest ICD coding updates and guidelines can also help reduce these errors.
2. Denial Code 15 (CO-15)
Authorization or Pre-Certification Absence Reason.
This code is used when a service is provided without authorization or pre-certification from the insurance provider.
How to Address It:
Implement a robust verification system that checks for required authorizations before providing services. Training front desk staff to verify insurance coverage details and obtaining pre-authorizations can drastically reduce these denials.
3. Denial Code 16 (CO-16)
Claim/service lacks information for adjudication.
Insufficient information on the claim can prevent the insurer from making a payment decision.
How to Address It:
Develop a claim submission checklist that includes all necessary documentation and information and implement electronic claim tools that flag missing information to catch errors before submission.
4. Denial Code 18 (CO-18)
Duplicate claim/service.
This denial occurs when a claim is submitted more than once for the same service for the same patient on the same date.
How to Address It:
Use practice management software that includes duplicate checking features. Regularly train staff on proper billing practices to ensure claims are not mistakenly submitted multiple times.
5. Denial Code 29 (CO-29)
The time limit for filing has expired.
Claims must be submitted within a specific time frame. Failure to do so can result in denial due to the expiration of the filing limit.
How to Address It:
Implement a system to track and monitor claim submission dates. Automate reminders for pending claims to ensure timely filing and minimize the risk of this denial.
6. Denial Code 204 (CO-204)
Service/equipment/drug is not covered under the patient’s current benefit plan.
The billed service is not covered under the patient’s insurance plan.
How to Address It:
Verify coverage for the specific service, equipment, or drug prior to service delivery. Educating patients about their coverage limits and alternatives can also help manage their expectations and prevent this denial.
7. Denial Code 253 (CO-253)
Medicare sequestration adjustment.
This code refers to the mandatory reduction in federal payments as part of budgetary recovery.
How to Address It:
Since sequestration adjustment denials cannot be avoided, focus on accurate claim submissions for other aspects to offset financial impacts. Understanding and forecasting the impact of sequestration on reimbursements can aid in financial planning.
8. Denial Code 167 (CO-167)
The lifetime benefit maximum has been reached for this service/benefit category.
The patient has exceeded the maximum benefit limit set by their insurance plan for a particular service or treatment category.
How to Address It:
Implement an insurance verification step during patient check-in to review benefit maximums. Educate staff to discuss alternative payment options with patients when limits are reached.
9. Denial Code 22 (CO-22)
Payment is adjusted because another payer may cover the procedure per the coordination of benefits.
Denial occurs when another insurer is responsible for payment, either partially or fully.
How to Address It:
Establish a protocol for checking patient coverage under all applicable policies and coordinate benefits accordingly before processing claims.
10. Denial Code 97 (CO-97)
The benefit for this service is included in the payment/allowance for another service/procedure already adjudicated.
Payment for a service is bundled into another service already claimed and adjudicated.
How to Address It:
To prevent CO-97 denials, make sure your current coding practices are accurate, up-to-date and reflect current bundling rules. Continuous education on coding changes and frequent audits can help maintain compliance and accuracy in claim submissions.
Claim denials are one of the top issues hindering the revenue cycle in healthcare, and while they cannot be avoided, there can be a proactive approach to reduce its rate. From staff training in patient intake information to accurate coding and efficient billing, several targeted strategies can help centers take control of their cash flow and maintain a healthier revenue cycle.
Our team is ready to help you recover lost revenue and improve your center’s billing process. Explore our Billing & Coding Services to learn more about how we can assist you in taking proactive steps toward a more efficient and profitable practice. Explore our Billing & Coding Services.
