CO-4 denial code

One of the most prominent denials in the medical billing industry is CO-4 denial. Insurance may deny the claim for the various reasons for  CO 4 Denial Code such as CPT and modifier combination is incorrect, Procedure code is not valid one to bill for the rendered service. or the Modifier billed is not required for the Cpt.

Hence to eradicate this type of denial there are a few important steps you have to look at. Make sure you check the last Questionnaire flow chart for understanding the complete concept in processing the claim.

First, look what is the denial. if it is something related to coding and correction needed from our side. Check with the coder for the possibility of appropriate code to be corrected. The coder will look at those claims and check for the correct combinations stating what code perfectly matches for payment.

After adding the correct valid Procedure code. Remember, you have to send a corrected claim with freq-7 marked on the Claim form. Freq-7(show it is Corrected claim)

Modifier

Two-digit alphanumerical or numerical code billed along with the Cpt code to differentiate the service or adding more specification about the service called as Modifier – Example – GW, 25, TC, 26

The same steps are followed for the modifier issue, if you get the denial as an incorrect modifier or the modifier and Cpt combination is invalid.

Check for the coder, if you find the appropriate modifier add it to the procedure code and resubmit it as a corrected claim marked Freq-7(show it is Corrected claim)

What if the coder says the procedure and the modifier billed is valid?

If the claim was denied stating CO 4 -The procedure code is inconsistent with the modifier billed or a required modifier is missing for service billed. You have to check for coding.

If the coder says the billed CPT and modifier combination is right then you have to send the claim back for review witnessing the coder’s statement to the payor.

When the payer agrees with your statement they will send the claim back for reprocess and pay the claim. if the representative denies your reprocess request you have to appeal the claim. That should be your last choice.

Questionnaire flow chart  for CO-4 denial code

Make sure you ask these details with a representative for CO-4 denial code

1	May I get the denied date?
2	May I get the denial reason?
3	If the claim is denied for modifier and procedure code inconsistent
	Ask for the Modifier and Cpt
	Check with coder
	If the coder says it is wrong —- >Ask him to correct the code and send the claim as a corrected claim
	If the coder says it is Right——> Send the claim back for reprocessing
	If rep denies sending the claim back for reprocess —> Then appeal claim with supporting documents
	Claim number #
	Call reference number #