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5 Recurring Reasons for Denials in Laboratory Claims

10-30% of Laboratory Claims are denied the first time after submission. This alarming factor leads to a significant loss in revenue.

Understand denials and implement prevention strategies.

AltuMED Medical Billing helps its clients overcome denials and achieve 97% FTPR. In 15+ years of medical billing, we have noted common denials for laboratory claims.

10% to 30% of lab claims are either denied or rejected the first time after submission.

1. Missing/wrong CLIA number

Independent labs must submit CLIA numbers by certification type.

  • Certificate of Waiver: CLIA certificate for waived tests only.
  • Certificate for Provider-Performed Microscopy Procedures: CLIA certificate for physician/midlevel/dentist microscopy only. This certificate permits the laboratory to also perform waived tests.
  • Certificate of Registration: CLIA certificate for moderate/high complexity testing until compliance survey.
  • Certificate of Compliance: A CLIA certificate is issued after compliance inspection.
  • Certificate of Accreditation: CLIA certificate based on accreditation by a CMS-approved organization.

2. CO-50, CO-57, CO-151, N-115 LCD/NCD Denials

CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under an LCD/NCD

Check the LCD or NCD prior to service to determine the patient’s eligibility for services. If service not in LCD guidelines, give patients ABN before tests.

3. 109/N104/190/N106 N538 Non-Covered by this Contractor

109/N104/190/N106 N538 - Check patient eligibility before submitting claims.

Refer to the Eligibility section

  • The patient may be enrolled in a Medicare Advantage (MA) plan.
  • Refer to the Inpatient section for service during hospital/SNF stay.

4. M127 Medical Notes Missing

M127 Medical Notes Missing – The payer needs medical notes for the claim processing. Documentation Requirements: the following records need to be submitted to the payer:

  • Progress notes or office notes
  • Physician order or intent to order
  • Laboratory results

5. CO 11 – Diagnosis Inconsistent with Procedure

CO 11 denial– Coding error with diagnosis.

That’s the first thing to check if you get this type of denial. Double-check that ICD-10 matches services and LCD/NCD policy. Knowing denial reasons aids in improving lab billing process.

AltuMED Medical Billing pushes its clients to conduct thorougah Medical Billing Performance Analysis that helps identify such latent reasons behind faulty medical billing process. We then provide our clients with real time, actionable reports that yield efficiency in their processes within first 3 months, follow the link to get started with Medical Billing performance analysis for your lab.

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