Top 10 Denial Codes in Medical Billing

Health insurance providers use standardized denial codes to describe their decisions not to pay or reimburse a medical claim. Along with a brief explanation of the refusal, these codes are frequently given on the insurer’s remittance advice. Health insurance providers provide these codes to claims that cannot be processed.

Denial codes can have various root reasons, including inaccuracies in the coding, non-covered benefits, a lack of supporting documentation or authorization, policy exclusions, billing restrictions, eligibility problems, and problems with the need for medical care.

The financial stability of healthcare providers can be significantly impacted by claims denial, which frequently happens in medical billing. To prevent claim denials in the future, it is essential to comprehend the reasons behind them. Medical billing denial codes explain why a claim was rejected, assisting institutions in locating and resolving the problems that caused the denial.

Get comfortable as we explore the most common medical billing denial codes.

What are the most common denial codes?

The top 10 denial codes in medical billing typically include:

1. Denial code 18

When an insurance provider issues a denial code 18, it signifies that the claim is a duplicate of one already submitted. The insurance provider will compare a claim submitted by a medical provider to prior claims to ensure no copies.

The claim will be rejected with denial code 18 if the insurance provider determines it to be a duplicate.

This may occur if the medical provider submits the same claim multiple times or the insurance company receives multiple claims from various providers for the same service.

Both the patient and the medical practitioner may find it frustrating when there are delays in processing due to duplicate claims.

Healthcare providers can prevent refusal code 18 by filing each claim only once and precisely including all required information with the claim.

2. Denial code 22

Denial code 22 happens when an insurance company determines that the patient has additional health insurance that may be liable for settling the medical claims submitted. The insurance company learns that the patient might have other coverages that still need to be invoiced, which is when Coordination of Benefits (COB), another name for this situation, occurs.

COB aims to ensure that medical care costs are distributed among various insurance providers and that no insurance provider pays more than the total cost of the covered service. As a result, the insurance provider will refuse the claim with denial code 22, advising the medical practitioner to verify the patient’s insurance information or see if another insurance provider has invoiced for the service.

Medical billing professionals or providers must be alert and aware of the applicable Coordination of Benefits guidelines to avoid such scenarios, which can result in lost income and dissatisfied patients.

3. Denial code 29

When an insurance company rejects a claim, it usually happens because the provider missed the deadline for submitting the claim. This is indicated by the denial code 29 in medical billing. Each insurance company has a deadline for claims after service.

The insurance provider’s contract and local, state, or national regulations usually set the timetable. When a claim is filed after this deadline, the insurance provider will reject it with the rejection code 29: “The time limit for filing has expired.”

A disallowed claim due to a missed deadline would result in a write-off, which can result in a significant loss of income for healthcare providers. Medical billing staff or providers must regularly check in on and monitor filing deadlines, train their staff to be aware of these time constraints, and submit claims quickly to prevent denial code 29.

A streamlined procedure for submitting claims and standards for accurate data collection and timely documentation must be in place. Furthermore, providers should be aware of the timescales they have agreed to with each payer and modify processes accordingly.

04. Denial code 45

An insurance carrier may partially or completely deny a claim if the amount charged for a particular service exceeds the insurance provider’s maximum authorized or fee schedule, as indicated by the denial code 45 in medical billing.

Every insurance company establishes maximum costs for various services, also known as the “maximum allowable.” Providers must charge within the fees buyers are willing to pay, or the difference will be written off.

When services are rendered for amounts more significant than or equal to the permitted fees, Denial Code 45 may be issued. Understanding the approved fee schedule of the insurance providers they interact with will help providers avoid refusal code 45.

Medical billing staff must be well-versed in CPT codes and the fees that correspond with them, pay close attention to the payment schedules of each insurance provider, and adequately charge the suggested code and related costs.

Providers must also keep up with changes in fee schedules or rates to ensure that they bill within the allowed limitations. It’s essential to consider additional fees like copays that could result in an overpayment.

05. Denial code 96

When an insurance company determines that a claimed procedure is not medically required or does not match their eligibility requirements, it is known as a denial code 96 in medical billing. The treatment or service may be seen as experimental or not clinically valuable for the patient’s situation. When someone denies the service or procedure, they often refuse to pay for some or all of the cost.

The service given is not a benefit covered by the patient’s policy, as indicated by the denial code 96. Medical billing staff and providers should take reasonable steps to ensure that their patients only receive treatments covered by their health insurance plans to prevent refusal code 96.

Clinical judgment and communication with patients and insurance companies are essential to avoid this kind of denial, which can be challenging and time-consuming to overturn. Additionally, completing pre-authorization or talking to the insurer about the service’s medical necessity can assist in avoiding problems with medical conditions.

06. Denial code 109

When an insurance provider decides their plan or insurance agreement does not cover a patient’s surgery or medical service, they use the denial code 109. Exclusion from an insurance policy is denoted by the denial code 109. Insurance companies frequently offer detailed lists of perks and coverages for specific health plans.

The insurance company will generally deny the claim with denial code 109 if any medical care exceeds the coverage limits of these plans. Before performing any medical services or treatments on the patient, medical billing staff and providers should thoroughly review the patient’s insurance coverage to prevent denial code 109.

To confirm if the patient’s healthcare plan covers the surgery or medical service, they should look up their insurance coverage, including policy exclusions and limits. Only those services that fall under the policy’s defined coverage limits should be billed by providers. Keeping the payer or insurance informed is crucial to prevent disputes over denial code 109.

07. Denial code 197

Medical billing’s denial code 197 denotes a claim being denied because the billed service, expense, or procedure has not been recognized. In general, this denial means that the insurance company has prohibited the billed costs or adjusted the claim that the provider submitted because it does not have the authorization to pay.

When there is a discrepancy or inaccuracy in the data of the authorized healthcare provider, denial code 197 is frequently utilized. A practitioner may often need the proper referral, prior authorization, or pre-certification for a service or procedure.

Offices can set up a trustworthy warning system and authorize services that demand prior authorization, certification, or referral to avoid denial code 197. Billers, providers, and staff who arrange those services may work together.

Additionally, offices have access to relevant patient data, may proactively engage with patients regarding any pre-approval required for specific procedures, and can accurately interact with insurance companies when applying for authorizations. It is advantageous to maintain thorough records of earlier authorizations and referrals and to set up procedures to ensure staff members confirm this data.

08. Denial code 204

Medical billing denial code 204 denotes that the insurance company packaged or combined the invoiced service, item, or treatment unexpectedly or improperly. Alternatively, it is referred to as the packed service denial code. A packaged service is a service or process combination that describes many services or procedures. Bundling is a legal process combining two or more operations listed under the same CPT-4 code or when the care is part of a more comprehensive therapy and cannot be billed separately.

When a claim is submitted, and unbundled codes previously generated as part of a service, method, or combination are included, the denial code 204 may be issued. In this case, the payer will only approve the procedure, service, or blend and either reduce or reject any further bills.

Medical billing providers must maintain a thorough awareness of bundled and unbundled codes, the specifics required to correctly code and charge their services, and other related requirements to prevent refusal of code 204. Before submitting a claim, billing employees must ensure they adhere to the proper coding standards and conduct a rigorous check of all charges to spot bundling problems.

Providers and billing personnel should thoroughly review the extracted explanation of benefits (EOBs) to spot any inaccuracies. The claim should then be reworked and submitted with more accurate reporting.

09. Denial code 252

Medical billing’s denial code 252 indicates a potential problem with the Coordination of Benefits (COB) clause. It occurs when an essential payer other than the billed insurance provider has already paid for a particular service’s price. The COB process generally seeks to avoid paying out duplicate or excessive amounts for medical claims.

When the insurance payer bills fees for services that the primary insurance has already covered, the denial code 252 happens. For instance, if a patient has primary and secondary insurance coverage and the primary insurer has already paid the associated expenses, the secondary insurer will deny the claim, and the billing company will be given denial code 252.

Medical professionals should take the time to verify the patient’s insurance eligibility and benefit coverages to ensure that the primary insurance policy covers the billed expenditures to avoid denial code 252. Additionally, it’s critical to maintain a thorough patient registration procedure to avoid authorization, charge collection, and billing errors—all of which frequently result in COB problems.

Providers should communicate effectively with their patients to determine which insurance provider should be billed first and have a thorough awareness of their insurance policies. The clinic can adhere to the guidelines by communicating well with the insurance companies.

10. Denial code 253

When a patient has received all permissible benefits or services for a given period, the denial code 253 in medical billing indicates this. It denotes that the insurance policy’s specified period, frequently monthly or annually, has reached the maximum for the service code for which a bill is issued.

This rejection number is used when a patient’s insurance limits how many treatments they may obtain. A patient may be limited to several yearly laboratory or physical therapy services.

If a patient has utilized all of the services permitted for them to obtain over a given period, the billing provider will receive denial code 253.

Medical practitioners or billing staff should keep an eye on patients’ insurance coverage or benefit limits to accurately represent what services or benefits are covered during the particular term period to avoid denial code 253.

Patients must know their benefits and provider constraints. Clinical staff must coordinate care and monitor remaining coverage to assist patients in maximizing it. Providers should create an exception handling and appeals mechanism to challenge these constraints or negotiate more benefits. They should also attempt to track any limitations as soon as possible.

Conclusion

Providers frequently need help with medical billing denial codes. They harm a provider’s revenue cycle and, if left unattended, can result in severe revenue loss. By knowing the most typical denials, providers can lessen the likelihood of denied claims.

To reduce these denials, practitioners should keep correct patient records, verify insurance eligibility, follow billing and coding best practices, and communicate with patients and insurance providers to resolve concerns quickly. Practical approaches to these problems would prevent revenue loss and help patients by guaranteeing timely access to high-quality care.