RCM – Claim Denial Codes
RCM – Claim Denial Codes
How can you better optimize your RCM?
The golden question involving over a million different answers. Where do you start though, with the countless articles claiming unreasonable results with very little effort? Where do you begin when every website has different tips and tricks that don’t seem like they’d make much of a difference? The goal of this blog is to help wade through all the mess to ensure quality advice from those who have done the optimization and have received results.
Controlling the RCM from the front-end is vital to the success of a practice. One of the basic but important steps in optimization is understanding claim adjustment reason codes when a claim is denied.
Understanding why claims are often denied and what error codes mean is the first step in not only quickly troubleshooting these claims but also in taking preventative measures so that claims go through smoothly upon their first submission.
Common Claim Adjustment Reason Codes
- 96 – Non-covered charge(s) – This indicates the service billed was not covered by Medicare. There is no way to resubmit this claim and expect it to be approved, so be sure to double check what services are covered by Medicare. Use this resource to check exceptions.
- 109 – Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor – Some services must be billed to different contractors. This error message is received when the claim is sent to the wrong contractor. To resolve, simply resubmit the claim to the correct contractor.
- 18 – Exact duplicate claim/service – When submitting a claim, the IVR can be used to ensure a claim isn’t still being processed. If a claim is re-submitted while the original is still being processed, this error code will be received.
- 50 – These are non-covered services because this is not deemed a ‘medical necessity’ by the payer – There is a large number of resources to aid in determining if a questionable service can be deemed “medically necessary,” which will ensure payment. These three resources can be used as a reference:
- 97 – The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated – This error indicates that a different service performed at the same time included this service, so both should not be billed.
- 49 – These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam – When a routine exam is done, only the exam can be billed. Any services provided within the scope of the exam cannot be separately billed, as they are covered under the exam service.
- All other Claim Adjustment Reason Codes can be found at this
Don’t let the complexity of Adjustment Codes overwhelm you
With over 100 different codes, explaining why a code is denied can be a complicated process. Researching and analyzing some of the most common, however, can allow preventative measures to be taken so that claims can be easily accepted. Creating a clean claim from the beginning establishes a healthy RCM system from the front-end.
