Eight Common Denial Codes and How to Prevent Them

Blog
Article Background

Claim denials deliver a double whammy to the bottom lines of rural and community healthcare providers, both in terms of lost revenue and in the administrative costs involved with appealing, reworking, and resubmitting claims. However, contrary to conventional wisdom, claim denials aren’t typically the result of rare or complex issues. Rather, they often stem from common billing and documentation errors, frequently repeated over and over.

At a time of razor-thin margins across healthcare, preventing these denials makes a lot of fiscal sense. But where should you focus your preventive efforts? Based on findings from TruBridge coding and billing experts, the following chart summarizes eight of the most common medical billing denial codes and reasons why they occur, along with practical steps and tools for preventing these denials.

Code 

 Description  Common reason(s) 

Preventive steps/tools 
CO-97  Service Not Covered or Not Deemed Medically Necessary  Procedure not covered by payer or lacks medical necessity documentation; often due to missing prior authorization or incorrect use of CPT codes 

 

 Prior authorization checks; clinical documentation improvement (CDI) initiatives; payer-specific training 
CO-22  Claim Submitted Incomplete or Missing Information  Required claim fields (e.g., patient demographics, diagnosis codes) are left blank or have incorrect information 

 

 Front-end data validation tools; EHR-integrated prompts; claim scrubbing software 
CO-16  Claim/Service Lacks Information Needed for Adjudication  May refer to missing claim attachments, service details, or provider identifiers 

 

 Automated claims tracking; detailed denial reason capture; use of TruBridge clearinghouse tools 
CO-252  An Attachment/Other Documentation Was Required  Missing documentation, such as operative report, referral, or medical record; common with surgical or DME claims 

 

 Streamlined document management; auto-alerts for required attachments; integrated fax-to-EHR systems 
CO-4  The Procedure Code Is Inconsistent with Modifier or Provider Type  Modifier errors; billing of services outside provider’s scope; often occurs in specialty practices or when billing incident-to incorrectly 

 

 Modifier validation tools; regular staff education on CPT guidelines 
CO-23  The Impact of Prior Payments on Claim Adjudication  Service has already been paid or bundled with another service; may result from uncoordinated billing across departments or duplicate submissions 

 

 Internal pre-submission reviews; improve coordination between billing and clinical teams 
CO-11  Diagnosis Code Does Not Support the Procedure  Procedure and diagnosis mismatch; commonly due to confusion over routine wellness vs. problem-oriented visits  

 

 Improve encounter-level documentation; diagnosis coding audits 
CO-18  Duplicate Claim Submission  Submission of subsequent claim before payer response to initial claim 

 

 Claims management tools to track payer responses and prevent accidental re-entry 

Denial Codes Aren’t Just Codes, They’re Clues to Revenue Cycle Issues

It’s essential to see denial codes for what they really are: clues to systemic issues in revenue cycle processes — often coming with costly consequences. The problem is, many smaller organizations simply cannot devote sufficient resources to proactively identifying and resolving the root causes of denials.  

After carefully weighing the potential return on investment, a growing number of rural and community providers have outsourced their denial management to an outside firm with special expertise in this area. The right partnership can yield significant benefits, including increased cash collections, maximized reimbursements, and improved overall revenue cycle efficiency. 

TruBridge offers a proven set of Denial Management solutions. Built on best practices and insights from the Healthcare Financial Management Association (HFMA), our coding and denial management services removes a huge burden from internal revenue cycle management (RCM) staff. At the same time, it positively transforms workflows, reduces denial-related revenue loss, and increases organizational efficiency.

For organizations also managing aged receivables, the TruBridge A/R Recovery Workdown solution supports effective follow-up and cash acceleration. 

The TruBridge Proven Process for Smarter Denial and Coding Management

Step 1: Analyze, prioritize, and report — Electronic analysis of 835 remittances and 837 claims data yields valuable insights; this is followed by categorization and prioritization of denials into key areas, including number of claims and corresponding revenue opportunities.
Step 2: Assess and Address Root Causes Our team conducts an onsite or virtual assessment of your existing workflows from patient registration through claims submission to identify what’s driving denials. We identify documentation gaps, coding inconsistencies, and process inefficiencies, then implement best practices, automation, and workflow improvements tailored to your team’s needs.
Step 3: Monitor, Track, and Improve To ensure long-term success, we partner with you to continuously monitor denial trends and performance. Through ongoing collaboration, reporting, and data analytics, we help fine-tune your revenue cycle processes and reduce repeat denials — so your staff can focus more on care and less on chasing claims.

TruBridge denial management services help organizations analyze patterns, reduce denial rates, and improve cash flow by resolving root causes, not just symptoms.