The diagnosis was not valid on that date of service.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Fix and resubmit. This is a correction, not an appeal. Appealing burns the deadline.
In the order we see it.
The diagnosis was deleted or revised in the annual October update.
A code was used before its effective date.
Check the diagnosis against the ICD-10 set in force on the date of service, then rebill.
The documentation, not the argument.
The diagnosis code valid on the date of service.
The common mistake. Do not appeal. The October changes catch out claims that span the boundary, and a correction is faster than an argument.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound