How can providers enhance their collection potential? One approach is to minimize denials, although this is often challenging if denials aren’t being analyzed, appropriate protocols for resolution aren’t followed, or adequate training isn’t provided to the collections team. This article aims to offer guidance on tackling a common denial that providers face: the CO16 denial, which signifies that essential information is lacking for adjudication.
When confronted with a co16 denial code, the initial step is to examine accompanying remark codes. These codes provide further context about the missing information. If these definitions aren’t readily accessible, you can refer to the comprehensive lists of Claim Adjustment Reason Codes (denial codes) and Remittance Advice Remark Codes hosted by the Washington Publishing Company. Let’s start by exploring some of the various remark codes linked to CO16.
1. Remark Code M60:
This code highlights the absence of a necessary Certificate of Medical Necessity (CMN) or DME MAC Information Form (DIF) on the claim. Sometimes, the issue might stem from an incorrect linkage of the CMN to the claim within the provider’s software. While this is an evident omission in the case of an oxygen or enteral patient’s initial claim, it might be less obvious when taking over a patient from a previous supplier, and the status of the prior CMN or DIF hasn’t been investigated.
For instance, if a Group I oxygen patient is transitioned from a previous supplier in the sixth month of rental without a service break, the recertification CMN will be required sooner than the standard one-year interval from the initial CMN. While having complete information about the previous CMN can prevent the denial, if the denial is received, rectification is straightforward by resubmitting the claim with the required CMN attached. This applies to any type of CMN or DIF required for the claim. Some providers try to address this denial through redeterminations or re-openings, but resubmitting and processing within 14 days is much quicker.
When confronted with a CO16 denial, the initial step is to examine accompanying remark codes. These codes provide further context about the missing information. If these definitions aren’t readily accessible, you can refer to the comprehensive lists of Claim Adjustment Reason Codes (denial codes) and Remittance Advice Remark Codes hosted by the Washington Publishing Company. Let’s start by exploring some of the various remark codes linked to CO16 denial code.
2. Remark Codes N264 and N575:
N264: Incomplete/invalid ordering provider name.Â
N575: Discrepancy between submitted ordering/referring provider name and records.
A CO16 denial doesn’t always indicate missing information; it might signify invalid data. For instance, post the 2014 implementation of the PECOS enrollment requirement, DMEPOS providers encountered CO16 denials when the ordering physician wasn’t enrolled in PECOS. The N264/N575 remark codes denote this situation. Even a minor difference in the spelling of the ordering physician’s name on your claim compared to their PECOS enrollment can lead to denial.
While such denials were common post-implementation, they persist as physicians fail to renew their enrollment. In such cases, promptly contacting the physician for recertification is vital. Once this is done, you can resubmit the claim for payment.
For instance, if a Group I oxygen patient is transitioned from a previous supplier in the sixth month of rental without a service break, the recertification CMN will be required sooner than the standard one-year interval from the initial CMN. While having complete information about the previous CMN can prevent the denial, if the denial is received, rectification is straightforward by resubmitting the claim with the required CMN attached. This applies to any type of CMN or DIF required for the claim. Some providers try to address this denial through redeterminations or re-openings, but resubmitting and processing within 14 days is much quicker.
When confronted with a CO16 denial Codes, the initial step is to examine accompanying remark codes. These codes provide further context about the missing information. If these definitions aren’t readily accessible, you can refer to the comprehensive lists of Claim Adjustment Reason Codes (denial codes) and Remittance Advice Remark Codes hosted by the Washington Publishing Company. Let’s start by exploring some of the various remark codes linked to CO16.
3. Remark Code M124:
Encountering the M124 remark code on the explanation of benefits indicates an omission regarding whether the patient owns the equipment requiring the part or supply. This might happen when billing supplies or accessories for a new fee-for-service Medicare patient whose base equipment wasn’t billed through Medicare. In such instances, Medicare mandates adding specific information to box 19 on the CMS-1500 form or the NTE field for electronic claims: HCPCS code of the base equipment, a note of the beneficiary’s equipment ownership, and the equipment receipt date. This information is also essential for repair items not covered by Medicare.
To secure payment for the claim, you’ll need to obtain the base equipment details, include them in the NTE field or box 19, and re-submit to Medicare. Given limited space, using approved abbreviations is crucial to include all necessary info.
4. Remark Code N350:
Medicare deploys the N350 remark code for a missing/incomplete/invalid service description under a Not Otherwise Classified Code.
For example, using code E1399 when the item provided doesn’t match an established HCPCS code triggers the N350 remark code. When billing such codes, box 19 on the CMS-1500 form for paper claims or the NTE field for electronic claims should contain: Product Name, Make/Model of Item, and MSRP. Rectifying this denial necessitates including this information and re-submitting the claim.
For commercial payers, CO16 can bear diverse meanings. Primarily, it indicates that additional information from the provider is needed before processing the claim. This might involve missing or invalid authorization, primary explanation of benefits, accurate diagnosis, or even medical records substantiating the patient’s item requirement.
When a commercial payer issues a CO16, start by reviewing any remark codes on the ERA, paper EOB, or payer’s website. If the denial’s cause isn’t sufficiently explained, contacting the payer for clarity is the next step. Once you gather the required information, ensure you understand how to submit the corrected or missing details per the payer’s specifications. The submission method varies among payers, ranging from resubmissions to corrected claims or faxed information along with forms. The specifics and required information locations on the claim differ too. Communicating these details effectively with your collectors is vital for swift payment attainment.
