3811 Ditmars Blvd# 1124, Astoria, NY 11105

Get the Complete Healthcare Practice Aduit Report

Edit Template

Top 10 Denial Codes in Medical Billing - Expert Results to Maximize Revenue

Name: Cures Medical Billing Services Company
Address: 3811 Ditmars Blvd# 1124, Astoria, NY 11105, Astoria, NY, 11105, USA
Telephone: +1 (917) 994-9941

As a medical billing expert with 15+ years of experience, I’ve seen denial codes cripple revenue cycles. The key to reducing claim rejections? Decoding why denials happen and acting fast. In this guide, I’ll list the top 10 denial codes, their causes, and actionable fixes, plus pro tips to strengthen your billing process.

Understanding Denial Codes - The Backbone of Claim Resolution

Denial codes are alphanumeric codes (e.g., CO, PR, OA) that insurers use to explain claim rejections. They fall into two categories:

Hard Denials: Irreversible without appeal (e.g., ineligible patient).
Soft Denials: Short-term, fixable with modifications (e.g., missing data).

Common formats include X12 denial codes (EDI standards like CO-22) and payer-specific codes (e.g., United Healthcare’s “N362”).

The Top 10 Denial Codes in Medical Billing + Solutions

CO-16: Claim/Service Lacks Required Information
- Cause: Missing/invalid patient ID, DOB, or policy number.
- Fix: Use automated claim scrubbers to flag incomplete fields pre-submission.
CO-29: Filing Deadline Expired
- Cause: Claim submitted past payer’s timely filing limit (e.g., Medicare’s 1-year window).
- Fix: Set calendar alerts for deadlines and batch-submit high-priority claims first.
CO-45: Charges Exceed Contracted Fee Schedule
- Cause: Billed amount higher than payer’s negotiated rate.
- Fix: Cross-check fees with payer contracts and update billing software annually.
CO-97: Claim Already Adjudicated
- Cause: Duplicate claim or prior payment already issued.
- Fix: Track claim status in real-time via payer portals to avoid resubmission errors.
CO-22: Coordination of Benefits (COB) Issue
- Cause: Primary/secondary insurer not correctly identified.
- Fix: Verify the patient’s active coverage hierarchy before submitting claims.
CO-4: Procedure Code Inconsistent with Modifier
- Cause: Missing or mismatched modifier (e.g., -25 for separate E/M service).
- Fix: Train coders on CPT®-modifier pairing rules and audit 10% of claims weekly.
CO-11: Diagnosis Inconsistent with Patient Age/Gender
- Cause: Invalid ICD-10 code (e.g., pregnancy code for male patient).
- Fix: Use AI-powered coding tools to auto-validate diagnoses.
CO-18: Duplicate Claim/Service
- Cause: Same claim submitted multiple times.
- Fix: Implement a claims-tracking system to flag duplicates in real time.
CO-27: Coverage Terminated
- Cause: Patient’s plan inactive on date of service.
- Fix: Conduct eligibility checks 24–48 hours before appointments.
PR-1: Patient Responsibility (Non-Covered Service)
- Cause: Service excluded from plan (e.g., cosmetic procedures).
- Fix: Protected ABN forms for non-covered services and gather upfront payments.

Pro Tip for AR Teams

Always cross-reference denial codes on EOBs with X12 code lists (e.g., CO vs. PR categories). For example:

- CO Contractual Obligation (payer-specific).
- PR Patient’s Responsibility (collect from patient).

Specialized Denial Codes by Payer

Medicare: MA130 (Missing ABN) – Always secure Advance Beneficiary Notices.
United Healthcare: N362 (Prior Auth Needed) – Confirm pre-authorization rules.
Workers’ Compensation: WC_CO-15 (Non-Covered Injury) – Document workplace incident details.

About Us

Our goal is to streamline your healthcare revenue cycle management, give you the financial freedom your practice deserves, and take control with a partner specializing in provider RCM optimization and services excellence.

Our Services

Recent Blogs

All Post
Medical
Uncategorised

97110 CPT Code – A Medical Biller’s Guide to Therapeutic Exercise

April 25, 2025

M17.11 ICD Code Comprehensive Guide to Right Knee Osteoarthritis

April 22, 2025

CO 197 Denial Code How to Resolve & Prevent Claim Rejections

April 21, 2025

How to Resolve Denials in AR Calling

Analyze EOBs: Match denial codes on Explanation of Benefits (e.g., CO-45).
Prioritize High-Impact Claims: Focus on codes like CO-22 (fast-approaching appeals).
Appeal Strategically: Include corrected claims, supporting documents, and a rebuttal letter.

Pro Tip: Use X12 denial code lists to decode EDI rejections (e.g., TA1-031 = invalid provider ID).

5 Proven Tactics to Prevent Denials

Train Staff: Regularly update teams on DHA denial codes (region-specific) and payer updates.
Check Claims: Pre-proposal checks reduce “missing data” errors by 60%.
Utilize AI Tools: Automate code lookup and trend analysis.

Final Thoughts

Hostile denials aren’t just about fixes, it’s about proactive prevention. Mastering denial codes (like CO-22 or PR-1) will slash rejections, speed up payments, and boost revenue. Need help? Our expert team resolves 95% of denials in <30 days. Book a Free Consultation.

Frequently Asked Questions (FAQs)

What are denial codes, and why do they matter?

Denial codes are standardized alphanumeric identifiers (e.g., CO-22, PR-1) used by insurers to explain why a claim was rejected. They matter because 30% of claim denials are preventable, and resolving them fast maximizes revenue.

What’s the difference between X12 denial codes and payer-specific codes?

X12 denial codes(e.g., CO, PR categories) follow national EDI standards and apply across insurers.
Payer-specific codes(e.g., United Healthcare’s “N362”) vary by insurer. Always check the payer’s code guide for clarity.

How do I fix CO-16 (“Claim Lacks Required Information”)?

Step 1: Identify missing fields (e.g., patient ID, DOB).
Step 2: Use automated claim scrubbers to validate data pre-submission.
Pro Tip: Train staff to double-check demographics during intake.

What does CO-45 (“Charges Exceed Contracted Rate”) mean?

This means you billed more than the insurer’s negotiated rate.

Fix: Review fee schedules annually and update billing software.
Example: If Medicare’s rate for CPT 99213 is 75,billing75,billing100 triggers CO-45.

Why do duplicate claims (CO-18) occur, and how do I stop them?

Cause: Human error or system glitches resending claims.
Fix: Implement a claims-tracking dashboard to flag duplicates in real time.

Are denial codes for Workers’ Compensation different?

Yes. Workers’ Comp uses codes like WC-CO-15 (“Non-Covered Injury”). Always document:
- Workplace incident details.
- Employer authorization.
- State-specific billing rules.

97110 CPT Code – A Medical Biller’s Guide to Therapeutic Exercise

M17.11 ICD Code Comprehensive Guide to Right Knee Osteoarthritis

CO 197 Denial Code How to Resolve & Prevent Claim Rejections

Physical Therapy Billing Units A Guide to Maximizing Reimbursements

Guide to Medical Billing Audit – Importance, Process & Benefits

The Ultimate Guide to Occupational Therapy CPT Codes & Billing (202

Top 10 Physical Therapy CPT Codes (+ How to Use Them)

CPT Code 92508 Billing Guide Reimbursement Rules & Avoid Errors

CPT Code 92507 the Ultimate Guide for Speech Therapy Billing

CPT Code 76817 Guide to Transvaginal Ultrasound Coding

States We Serve

Discover Cures Medical Billing Services Across Different States

Florida

New York

Maryland

Colorado

New Jersey

Arizona

Texas

California

Hawaii

Georgia

North Carolina

Washington

Your Success Is Our Success

We are a team of national medical billing service experts based in Astoria, NY, committed to providing ongoing value to our customers. We leverage technology and implement best practices to provide high-quality and cost-efficient medical billing solutions from domestic locations, enabling customers to achieve their business goals. Cures Medical Billing is the best option for any medical billing needs.

At Cures Billing Services, we prioritize collaboration and recognize the uniqueness of each healthcare provider or organization
Maximize your revenue by focusing on growing your practice and let us handle all the back-end billing processes.
We can customize reports to support your practice’s unique requirements

Medical billing around Astoria, NY, and beyond is our core competency and our specialists will efficiently manage all your billing needs. Our medical billing specialists have over 12 Plus years of experience with all security technologies to ensure data integrity for our customers. Using our medical billing service, anyone can make their medical billing task less resource-consuming.