CO12 Denial Code: Diagnosis is inconsistent with the Provider Type

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CO12 Denial Code: Diagnosis is inconsistent with the Provider Type

 

CO12 Denial Code: Diagnosis is inconsistent with the Provider Type

Insurance will deny the claim as Adjustment Code CO 12 – The diagnosis is inconsistent with the provider type, 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.

What is a Provider?

Provider means a person, agent, business, corporation, or other entity who, in connection with submission of claims to the Department, receives or directs payment from the Department on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider. There are following types of Providers

  • All Fee-For-Service Providers
  • Ambulatory Surgical Centers (ASC)
  • Ambulance Services
  • Anesthesiologists
  • Clinical Labs
  • Critical Access Hospitals
  • Durable Medical Equipment (DME)
  • Federally Qualified Health Centers (FQHC)
  • Home Health Agency (HHA)
  • Hospice
  • Hospital
  • Opioid Treatment Programs
  • Practice Administration
  • Pharmacist
  • Physician
  • Rural Health Clinics
  • Skilled Nursing Facility

Medical billing is one large system part of the overarching healthcare network. The healthcare network includes everything from medical billing to best practices for patient care, health institutions, and private practices.

Call Scenario:

  1. May I get the denial date?
  2. Could you please tell me which diagnosis code is invalid (If there are multiple DX code coded)
  3. Check patient payment history if the same DX code paid with same CPT
  4. IF Yes
  • Ask for clarification from rep and send claim back for reprocessing
  • What is the TAT for reprocessing?
  • May I have the claim# & call ref#
  1. IF No
  • What is the time limit to send corrected claim?
  • What is the Fax# or Mailing address to send an appeal?
  • How much is the time limit to send an appeal?
  • May I have the claim# & call ref#

Note:

  • This denial should be assigned to coding team to review and provide correct dx code and once response received with correct dx details then send corrected claim to insurance by updating correct dx code even if the time limit to send correct claim is crossed.
  • If coding team states that dx code is correct then send an appeal to insurance.
  • When sending an appeal, calculate the time limit from denial date, if it is not crossed then send the appeal or else write off the claim if time limit is crossed.
  • Sometimes client wants us to send the appeal even if time limit is crossed, so work accordingly.

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