Top 10 Denials in Medical Billing

Knowing the Top 10 Denials in Medical Billing

Having claims denied is a frustrating and common occurrence in the medical billing process. Denials disrupt your revenue cycle and create administrative burdens. Healthcare professionals need to comprehend why insurance organizations decline payments.

This knowledge helps them process payments smoothly and prevent frequent errors. 

In this blog, we’ll discuss the top 10 denials in medical billing and give tips on how to avoid them. Read on to optimize your denial management process.

What is a Medical Billing Denial?

A denial refers to any claim an insurance company rejected in whole or in part. When a payer denies your claim, they provide a denial reason or “code” to explain why they are not paying for the services rendered.

Some reasons for medical billing denials include missing information, coordination of benefits issues, procedural problems, benefit exclusions, and problems with qualifying and filing on time.

Denials in healthcare interrupt your facility’s cash flow and require appeal processes to overturn the payer’s decision. Understanding the most common denials is critical to avoiding claim rejections.

Related, How to Reduce Denied Claims?

The Top 10 Medical Claim Denials

Knowing why insurance companies reject claims can help lower denials and improve money flow. Denied claims can have a substantial effect on the practice. Here are the top 10 denials in medical billing formatted in code:

1. Denial Code 18 - Duplicate Claim

Definition

This code indicates you have submitted the same claim more than once, with no changes made. Payers see this as an exact duplicate submission for the same patient, provider, dates of service, and procedures.

Reasons

Mistakes in billing systems lead to double claims. Confusion among billers can result in accidental duplicates. Uncertainty about payer rules for resubmissions versus duplicates causes issues.

Prevention

Before sending claims, carefully check for duplicates. Create consistent procedures for fixing errors. Investigate denials to understand submission rules – train service staff on correct resubmissions and how to avoid duplicates.

2. Denial Code 16 - Claim/Service Lacks Information

Definition

The claim includes essential information the payer needs to process correctly. It has things like procedure codes, diagnosis codes, service details, and provider identifiers.

Reasons

Rushing claims, incomplete information, outdated codes, and lack of detailed descriptions contribute to the issue. It causes errors in billing and delays in processing claims.

Prevention

Before submitting a claim, carefully review it to ensure all information is complete. Verify the info against clinical records. Regularly update coding protocols and billing software as codes change. Provide regular coding education to clinical staff on documentation practices for optimal claim accuracy.

3. Denial Code 97 - Bundled Services

Definition

The payer believes the patient paid for the service with a different code during their visit. It means they think they have already covered the service.

Reasons

Outdated legacy billing practices, lack of coder education on evolving medical code edits and bundling rules, and complexity of coding guideline interpretations all cause denied claims.

Prevention

Look in CPT, CMS, AMA, and payer manuals for code meanings and bundling rules. Keep current on coding changes and payer guidelines. Use modifier codes on claims to separate services when necessary.

4. Denial Code 22 - Coordination of Benefits

Definition

The payer thinks another insurance company should pay first for the claim. They deny the claim because they believe they are the second insurance company responsible for payment.

Reasons

Confusion over patient policies and outdated insurance information can lead to mistakes in determining benefits between plans.

Prevention

Check insurance coverage before each visit, and ask for insurance card copies regularly to keep up with plan changes. Develop consistent processes for checking benefits data. 

You should train staff to apply rules for determining primary and secondary payers. Consider factors such as date of birth, marital status, disability, and employment when making these determinations.

Top 10 Denials in Medical Billing

5. Denial Code 29 - Timely Filing Limit Exceeded

Definition

You submitted the claim after the prescribed deadline set by that payer for claim receipt after the discharge or service rendered date. It leads to automatic denial due to the lateness of submission.

Reasons

There are delays in processing claims. It is challenging to track different filing deadlines with each insurance company. Backlogs in health records or billing are causing delays in submissions. There needs to be better coordination between clinical and billing staff.

Prevention

Use tools to help create claims from medical records for discharged patients. Create a procedure for keeping claim submission deadlines based on agreements with insurance carriers in mind. Reduce delays in managing health information by enhancing electronic medical record systems, workflows, and staffing levels.

Related, Can Medical Billing Services Help Grow Your Practice

6. Denial Code 96 - Non-Covered Services

Definition

The person paying for the services said the patient’s insurance or provider agreements do not cover them. They received information about this when they received the services.

Reasons

Recent changes to covered benefits were not conveyed to provider billing staff, and there were clerical oversights in benefit eligibility verification steps at patient intake workflows.

Prevention

Make rules to check if patients have insurance before giving services. Use technology, like eligibility verification systems, to check benefits. Workers must be updated frequently to keep up with changes to insurance plans.

7. Denial Code 109 - Not Covered by this Payer/Plan

Definition

The insurance company or health plan may deny claims for several reasons. The first is if the provider’s type, specialty, or credentials need to meet their approval. Claims can only be rejected if the provider is in the patient’s network. They can also be denied if the billing code for the services is not covered under the patient’s plan.

Reasons

The insurance company may only authorize care given out-of-network if they approve the provider. It can also happen if the provider’s status changes. If you do not update the billing system, the care given out-of-network may not receive authorization.

Prevention

Check the provider’s enrollment status. Verify which payers they have contracts with and the specialty privileges for each carrier. If a provider is out-of-network, add the proper modifier codes to their billing as allowed. Always seek the necessary authorizations for out-of-network care that needs an exception.

8. Denial Code 197 - Lack of Precertification/Authorization

Definition

It is a failure to obtain the required approvals from the payer before delivering scheduled health services to the patient.

Reasons

Ambiguity around which services require pre-authorizations, variability in recent guidelines between payers, and oversights by clinical staff in obtaining advance payer approvals.

Prevention

Keep an updated matrix that records the pre-authorization requirements for each payer based on the CPT codes for services. Train care coordinators regularly on the changing pre-approval rules. 

Set up pre-screening steps to determine the need for pre-authorization. Automated tools are used to manage these authorizations efficiently.

9. Denial Code 204 - Not Covered by Patient's Current Plan

Definition

The services billed were not included in the patient’s insurance coverage on the date they were provided. The active insurance policy did not cover the services billed then. As a consequence, the insurance provider might reject your request for coverage.

Reasons

They need to check for changes in a patient’s insurance plan since their last visit, which can cause issues. It’s essential always to recheck that the patient’s coverage is still active at each appointment. Also, problems can arise if patients present insurance cards that are no longer up-to-date.

Prevention

Make sure to recheck insurance details every time a patient comes in, right at the registration stage. Train the registration staff to recognize insurance policies correctly, not just by looking at the insurance card. Please encourage them to use online insurance portals to get the most current information on patient eligibility.

10. Denial Code 234 - Procedure is Not Paid Separately

Definition

The charged service code falls within another procedure performed for the patient on the same day. It happens due to coding rules that group some services. As a result, it cannot be billed separately.

Reasons

Billing separately for services under one code constitutes unbundling, which is incorrect. When services overlap but lack special codes to highlight their distinctness, they may appear duplicates. This perception can occur within the insurance review system. It can make the services appear to be incorrectly bundled or repeated.

Prevention

Always check the CPT and CMS manuals to understand which codes are bundled and which are add-ons before billing. Encourage coders to keep learning about changes in bundling rules to stay up-to-date.

Use special codes, such as -59, to indicate that services are separate parts of a single procedure. It helps make the billing process more precise.

Denial Details Definition Reason Prevention
Duplicate Claim
Same claim submitted twice without changes.
Billing system mistakes, confusion among billers.
Check for duplicates, establish error-fixing procedures, train on resubmission rules.
Claim/Service Lacks Information
Claim missing essential details.
Rushed claims, incomplete information.
Review claims thoroughly, update coding protocols.
Bundled Services
Services thought to be already covered.
Outdated billing practices, lack of education.
Stay current on coding, use modifier codes.
Coordination of Benefits
Another insurer should pay first.
Confusion over policies, outdated information.
Check coverage, train staff on benefit checks.
Timely Filing Limit Exceeded
Claim submitted late.
Processing delays, tracking difficulties.
Use claim creation tools, establish submission procedures.
Non-Covered Services
Services not covered.
Lack of benefit information, clerical errors.
Check insurance, use verification systems.
Not Covered by this Payer/Plan
Provider out-of-network or services not covered.
Lack of authorization, failure to update.
Check provider status and seek authorizations.
Lack of Precertification/Authorization
Approval not obtained before services.
Ambiguity, oversight.
Keep pre-authorization requirements and train coordinators.
Not Covered by Patient's Current Plan
Services not covered under the current plan.
Plan changes and outdated information.
Recheck insurance, train staff, and use online portals.
Bundled Procedure Code
Service falls under another procedure.
Unbundling errors, need for understanding.
Check manuals, keep learning, and use special codes.

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Overcoming Medical Claim Denials

There is a wide variety of denial codes payers can use to reject your medical claims. The tips for denial management in medical billing include:

  • Comprehensive payer policy education
  • Accessing denial analysis reports
  • Establishing efficient workflows
  • Updating practice management technology
  • Seeking continuous medical billing staff training

When claim problems arise, remain undeterred. Use denial management best practices to have your invoices paid properly and effectively. Contact our professional medical billers if you need to support appealing denials or improving your revenue cycle process.

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