Denial CO 11: Diagnosis is inconsistent with The Procedure

Denial CO 11: Diagnosis is inconsistent with The Procedure


Denial Code CO 11 – The diagnosis is inconsistent with the procedure

Insurance will deny the claim as Denial Code CO 11. Whenever the Procedure code billed with an inappropriate diagnosis code.

Diagnosis code (DX Code):

Diagnosis code represents the description of the disease. These codes are assigned by medical coding department by reviewing the medical reports in the format of ICD 10 Code.

In many cases, denial code CO 11 occurs because of a simple mistake in coding, and the wrong diagnosis code was used. That’s the first thing to check if you get this type of denial. Double-check with the coding department and the patient’s record to ensure there wasn’t a typo or to ensure a diagnosis wasn’t left out accidentally. If there were an error here, you’d need to correct the claim, and then resubmit it as a corrected claim.

If there was no error but you believe that the denial is in error, then you have the option to appeal the claim and provide medical records that back up the medical necessity of the procedure for this patient’s diagnosis.

1. First check whether payment received for previous DOS with same procedure and diagnosis code billed, then call and inform same to the claims department and send claim back for reprocessing.
2. Suppose payment not received or we don’t have previous DOS with same procedure and diagnosis, then the next step is to review medical records or to check with the coding team that the used diagnosis is really in-consistent with the procedure code billed and also check whether it’s billed as per LCD guidelines. If not then update the appropriate diagnosis and resubmit as corrected claim.
3. If the diagnosis billed is appropriate as per medical records and billed as per LCD guidelines, but insurance denied the claim incorrectly. Then reach out claims department and send the claim back for reprocessing.
4. If they disagree to send the claim back for reprocessing, final step is to appeal the claim along with medical records.
You can reach the claims department team with the following question to resolve the below denial:

  • May I know the Claim received and denial date?
  • First check which DX code is inappropriate with the procedure code billed and then in application for previous DOS whether we received any payment for same DX and procedure code billed.

If yes: Inform same to insurance and send the claim back for reprocessing.

If No: May I know appeal Limit, appeal address or Fax# to appeal the claim if necessary.(Check with coding team and take appropriate action as explained above)

  • Claim Number and Cal reference Number


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