CO12 denial code description and corrective action

• This denial occurs when the diagnosis code is not compatible with provider's specialty, taxonomy..

• Each provider has a specialty in a specific field of medicine, such as cardiology, podiatry, physical therapy, or psychology etc. If a diagnosis code used that does not fall within the provider’s specialty, the claim will be denied with this denial code.

• For example, if the provider is a podiatrist and we use diagnosis of mental health, then the claim will be denied because the diagnosis do not fall under the provider’s specialty.

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer.

• The most important step is to determine whether the claim denial is valid or if the insurance has denied the claim by mistake.

• Call the insurance company, if claims in the member’s history or history of any other patient with the same coding (diagnosis) and billed under same provider, have been paid, then we ask the representative to reprocess the claim. Be sure to note the claim number, rep name and call reference number, and then follow up on the claim after the provided TAT.

• We also check all provider information used in the claim is accurate or not. If we found something wrong then we submit corrective claim with correct provider's information.

• Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.

• Consult coding specialists or use reliable websites to determine whether the diagnosis is appropriate with provider's specialty or not..

• If the coding team confirms that the diagnosis can be used under respective provider, then we proceed with submitting an appeal.

• For submitting an appeal, we must calculate the timely filing limit starting from the processed date. If the limit has been exceeded, the claim will be denied again for exceeding the filing deadline. In such cases, we should consult with the provider. Some clients may still want us to submit the appeal even after the timely filing limit has passed, so we should proceed according to their instructions.

• If we determine that the denial is accurate and the coding team suggests the correct diagnosis, then we submit a corrected claim (or a new claim if the payer is Medicare). However, if the denial is accurate and there is no alternate diagnosis suggested by the coding team, we contact the client to inform them that the mentioned diagnosis cannot be billed under their specialty. After that, we proceed according to the provider’s instructions.

Description