How can providers boost their collection potency? Decreased denials are one solution. That’s sometimes easier said than done if you are not assessing your denials, following the necessary processes to resolve the denial through payment, or giving adequate training so that the collections staff understands how to manage the denial. In this article, I will provide you with advice on dealing with one of the most common denials that providers face. That refusal is the CO16—Claim/service lacks information required for adjudication.
When a CO16 rejection is issued, the first step is to examine any associated remark codes. These comment codes are used to specify what information is lacking. Let’s begin by going through some of the numerous remark codes with the CO16.
Remark Code M60
This code denotes that the claim lacks a necessary Certificate of Medical Necessity (CMN) or DME MAC Information Form (DIF). Sometimes the problem is as simple as the CMN not being appropriately connected to the claim inside the provider’s program. While this would be an apparent omission on the initial claim for oxygen or enteral patient, it may be a less evident problem if the patient was transferred from another supplier and the previous CMN or DIF status was not checked.
N264 and N575 Remark Codes
N264: The ordering provider name is missing, partial, or incorrect.
N575: Lack of consistency between the ordering/referring source and the records provided.
A CO16 refusal does not always imply that information is absent. It might also indicate that certain information is incorrect. For example, once the PECOS membership requirement was implemented in 2014, DMEPOS providers began to experience CO16 denials when the prescribing physician was not enrolled in PECOS. For indication, the N264/N575 comment codes are used. Also, even typing the ordering physician’s name differently on your claim than it appears in the PECOS enrollment might result in a refusal.
While these denials were common directly following implementation, they continue to occur as providers fail to recertify their participation. If this happens, it is critical to call the physician as soon as possible so that they can perform recertification. You will be eligible to resubmit the claim and get reimbursement whenever this occurs.
M124 remark code
Suppose you see this code on the explanation of benefits. In that case, it signifies a lack of indication of whether the patient possesses the equipment that needs the component or supply. That might be received if a physician is trying to bill supplies or attachments to a new fee-for-service Medicare patient who did not have their essential equipment billed via Medicare. In such cases, Medicare needs the following data to be included in box 19 on the CMS-1500 form or the NTE field on electronic claims: The HCPCS number for the base equipment, a statement that the beneficiary owns the equipment, and the date the patient got the equipment are all included. This data would also be needed for repair items in cases where Medicare does not cover the essential equipment.
The base equipment information must be retrieved, entered into the NTE field or box 19, and rebilled to Medicare to be paid on the claim. Since space is restricted on both box 19 and the NTE field, utilizing acceptable abbreviations is critical to adding all essential information.
N350 Remark Code
Medicare utilizes the N350 remark when there is a missing service description for a Not Otherwise Classified Code. An example of the N350 remark code would be charging an E1399 when the item delivered does not satisfy the definition of an existing HCPCS code. When paying for one of these codes, including the following information to box 19 on the CMS-1500 form for paper claims or the NTE field for electronic claims: Product Name, Make/Model of Item, and MSRP. The information must be added to the claim and rebilled to fix this refusal.
The CO16 might have a variety of implications for business payers. It is generally used to signal that further information from the provider is necessary before the claim can be handled. It might signal that authorization is lacking or invalid, that the principal explanation of benefits is missing or invalid, that the correct diagnosis is absent, or even that the payer wants medical evidence proving the patient’s need for the item received.
When you receive a CO16 from a commercial payer, the first place to check is at any commented code included on the ERA, paper EOB, or even the payer’s website. If the reason for the refusal is not sufficiently specific in a remark code, the next step is to call the payer to determine what information is necessary. Once the required information has been received, ensure that you understand how to transmit each payer’s updated or missing information. That will vary from payer to payer. Some payers may accept a resubmission; however, others will need revised claims or data to be sent to them, including a form. Adjusted claims may also need to be submitted on paper or electronically, depending on the payer, and may have particular information requirements in certain portions of the claim. It is critical to ensure that these facts are apparent to your collectors to get money as soon as possible.
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