diagnosis inconsistent denial - CO 11

CO 11  The diagnosis is inconsistent with the procedure. 

 Solution:

This denial indicates the procedure code billed is incompatible with the diagnosis.

• Before billing a claim, you may access the Procedure to Diagnosis look up/ Services Indication Report  to determine if the procedure code to be billed is payable under the specific diagnosis. 

• You may also refer to “ Local Coverage Determinations” for a list of procedure codes, relating to the services addressed in the LCD, and the diagnoses for which a service is/is not considered medically reasonable and necessary.

Tips to correct the denied claim :

If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• Do not resubmit an entire claim when partial payment is made; correct andresubmit denied lines only.

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Insurance denial - procedure code is inconsistent with the modifier

The procedure code is inconsistent with the modifier used or a required modifier is missing. Denial code 4

1.Modifier may be inconsistence with the procedure code
2. Modifier may be invalid for this procedure.
3. We may filed the claim without modifier.


Action : 
We need to check the modifier which we used it may be invalid or inappropriate. We have update and rebill the claim with correct modifier. 

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Claim denied as Invalid diagnosis code

INVALID DIAGNOSIS CODE

    The following types of rejections are possible; Diagnose code does not match with the procedure code (check in LMRP). The Diagnose code reported on the claim is not to the highest level of specificity. Diagnose code is no longer valid.  

    Action: Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry, if yes, Go ahead and change the correct Diagnosis.  If no, it may be because of incorrect Diagnose code. It is possible that the 4 digit Diagnose code used is not the highest level of specificity and the carrier wants a five digit Diagnose code. Coders will also have to recheck to see if the diagnosis code used has been deleted, if it matches with the procedure code and if it is of the highest level of specificity and if not find the right diagnosis code, correct it and refile the claim.

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Insurance denial - Invalid procedure code

INVALID PROCEDURE CODE

    Action: Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry. If yes, then correct code to be use. If not, check if the code used is correct with Encode pro, CCI Edits & LMRP.  If we have used a wrong code,  then goahead and change it and re-file the claim.  If no then there is one more reason for getting this type of rejection, the carrier may not be paying for some codes. In such cases we have to call the carrier and if the carrier says that they do not pay for the procedure than the amount has to be written off. There are cases where the primary may not be paying for one code whereas the secondary may consider the same. Medicare won’t pay for denial procedures whereas a secondary commercial may pay for the same.  In such cases submit the claim to the secondary insurance.

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