Top 10 Common Denial Codes in Medical Billing

Learn about the effects of denial codes on medical billing and how to avoid having your claim submissions rejected.

1. Title: Top 10 Common Denial Codes in Medical Billing
Description: Learn about the effects of denial codes on medical billing and how to avoid having your
claim submissions rejected.
Top 10 Common Denial Codes in Medical Billing
Understanding Denials in Medical Billing
Medical billing denials are prevalent and can have a substantial impact on a healthcare
organization’s income flow. Denials are the denial of a payer to approve a claim for
reimbursement, which is frequently influenced by remittance advice remark codes.
Understanding the causes of denials is critical for medical billing professionals to
successfully manage and resolve them.
Overview of Denials
Denials in medical billing occur when a payer rejects a claim for various kinds of reasons,
including missing information, coding errors, or a lack of medical necessity as specified
in the procedure codes. Healthcare institutions must monitor and evaluate denial
trends to discover improvement opportunities.

Commons Denial Codes and Descriptions
Denial code: 18
When the insurance company provides rejection code 18, it means that the claim is a
duplicate of one that has already been submitted. The insurance company will compare
a claim submitted by a medical provider to previous claims to verify there are no
duplicates.
Denial code: 22
Denial code 22 occurs when an insurance company discovers that the patient has extra
health insurance that may be responsible for settling the medical claims submitted.
When the insurance company discovers that the patient may have additional coverages
that need to be invoiced, this is referred to as Coordination of Benefits (COB).
Denial code: 29

2. When an insurance company rejects a claim, it is usually because the provider did not
file the claim by the deadline. The denial code 29 in medical billing indicates this. Each
insurance carrier has a deadline for filing claims after service.
Denial code: 45
An insurance company may partially or entirely deny a claim if the amount charged for a
certain service exceeds the insurance provider’s maximum permitted or fee schedule, as
indicated by denial code 45 in medical billing.
Denial code: 96
In medical billing, a denial code 96 indicates that an insurance company believes a
claimed procedure is not medically necessary or does not meet its required criteria. The
treatment or service may be seen as experimental or not clinically beneficial to the
patient’s situation.
Denial code: 109
When an insurance provider determines that their plan or agreement does not cover a
patient’s surgery or medical service, they use denial code 109. The Denial code 109
denotes exclusion from an insurance policy. Insurance companies usually provide
thorough lists of benefits and coverage for specific health plans.
Denial code: 197
Medical billing’s denial code 197 indicates that a claim has been denied because the
billed service, expense, or operation has not been accepted. In general, this denial
indicates that the insurance company rejected or changed the invoiced charges
submitted by the provider due to a lack of payment permission.
Denial code: 204
Medical billing denial code 204 indicates that the insurance company packaged or
combined the invoiced service, item, or therapy unexpectedly or incorrectly.
Alternatively, it is known as the packed service denial code.
Denial code: 252
Medical billing’s denial code 252 indicates a possible issue with the Coordination of
Benefits (COB) condition. It happens when a key payer other than the billed insurance
provider has already paid for a specific service’s cost.

3. Denial code: 253
In medical billing, the denial code 253 indicates that a patient has received all allowed
benefits or services during a certain period. The insurance policy’s stated time frame,
which is often monthly or annually, has reached its limit for the service code for which a
bill is issued.
Effect of Denials on Revenue
Denials can have a significant impact on a healthcare organization’s revenue because
they result in late or missed payments for services provided. Tracking remittance
guidance remark codes might help you understand and address reasons for denials.
High denial rates can cause financial instability and operational inefficiency.
Common Denial Reasons
Common reasons for claim denials include documentation issues, insurance coverage
concerns, and discrepancies in treatment and diagnosis codes. Addressing these issues
proactively may assist to reduce denials and improve revenue cycle management.
Addressing Claim Denials
Understanding the denial process, developing evaluations to reduce denials, and understanding the
role of medical billers’ ineffective claim denial management are all required.
Claim Denial Process
The claim rejection process comprises reviewing denial reasons, resolving issues, and resubmitting
claims for payment, which frequently requires review by the claims department. Quickly responding to
denials can help healthcare companies reduce revenue loss and improve cash flow.
Methods for minimizing denials
Implementing techniques such as conducting regular audits, providing staff training, and improving
documentation practices may help to reduce denials and boost billing efficiency, making insurance
companies less likely to deny claims.
Role of Medical Billers in Claim Denials
Medical billers perform a key role in claim denials by submitting valid claims, reviewing denial trends,
and collaborating with the billing team to resolve difficulties that result in claim rejections.
Common Reasons for Denial Codes
Common reasons for denial codes in medical billing include paperwork errors,
insurance coverage concerns, and variations in procedure and diagnostic codes, such as

4. incorrect procedure codes. Addressing these concerns could help healthcare companies
reduce denials and improve revenue cycle management.
Documentation Errors
Documentation issues, such as missing information or a lack of prior authorization, can result in claim
denials. Proper documentation practices and thorough verification of information, especially the date of
service, can help avoid these errors.
Insurance Coverage Issues
Issues with insurance coverage, such as benefit coordination and timely filing, might result in claim
denials. Verifying coverage and submitting claims within the directed date is critical for effective
payment.
variations between procedure and diagnosis codes
variations in procedure and diagnostic codes, such as utilizing inaccurate codes or recommending
services that are not covered, can lead to claim denials. Correct CPT codes can help to prevent such
disparities. Using precise coding techniques, including appropriate procedure codes, may help prevent
these errors.
Submission and Coding Practices
Importance of accurate submissions
Accurate claim submissions, including correct CPT codes, are critical to successful payment. Medical
billing professionals must ensure that all information, including modifiers and medical necessity
requirements, is accurately documented and presented to payers.
Using Modifiers Effectively
Modifiers play an important part in coding methods by providing additional information about the
services delivered. Using modifiers effectively communicates the complexity of services and can
influence payment amounts.
Medical necessity criteria
It is critical to show a procedure code's medical necessity to receive payment. Medical billers must
ensure that claims fulfil the medical necessity criteria established by payers to avoid denials.