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Claim Denial Data

Claims may be accepted as filed by Medicare systems but may be denied. CMS and CGS have established claim level editing to ensure services that should not be paid are appropriately denied. Many denials are due to reasons such as not meeting medical necessity; frequency limitations; and even basic coding mistakes.

Denials are subject to Appeal, since a denial is a payment determination. There are, however, some denials that can be avoided.

Below is a list of the monthly top denial reasons. Refer to resources available to you to avoid future denials.

Kentucky Top 5: January 2018

# of Denials Description Resource/Reference
44,493 Duplicate Service
  • Check the status of ALL claims before resubmitting
  • Submit multiple same services provided on same date on ONE claim
  • Use appropriate modifier to avoid duplicate denials (e.g., 50, RT, LT)
  • When resubmitting services initially rejected (message code MA130), DO NOT include services that were previously paid
    • For example: A claim is submitted with three line items. Two of the services are paid; one is rejected because the CPT code was invalid. When resubmitting a new claim with the corrected CPT code, do not include the two services previously paid, as they will deny as duplicate.
24,149 Code Submitted is for Reporting Purposes Only

Some providers are REQUIRED to participate in quality reporting programs. One method of participating is to submit non-payable measures on claims along with payable CPT codes. The non-payable codes are captured by CMS or our processing system to determine whether the provider successfully reported. Initiatives in place include:

NOTE: Because reporting is a requirement, this denial is not one that can be avoided.
22,318 Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer.

NOTE: The Medicare open enrollment period recently ended. Make sure your patients have not changed from traditional Medicare to one of the Medicare Advantage (MA) plans!
12,184 Payment is Included in Another Service Previously Adjudicated
  • Check definition of CPT/HCPCS codes to determine whether the code can be separately billed
  • Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services
  • The status of some CPT/HCPCS codes prevent them for being separately paid
    • Services with a status 'B' are always bundled, as payment is included in other services
8,795 Service Rendered Prior to Coverage

This denial is charged when our records show the patient did not have Part B coverage when the service was rendered.

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Ohio Top 5: January 2018

# of Denials Description Resource/Reference
83,170 Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer.

NOTE: The Medicare open enrollment period recently ended. Make sure your patients have not changed from traditional Medicare to one of the Medicare Advantage (MA) plans!
79,707 Duplicate Service
  • Check the status of ALL claims before resubmitting
  • Submit multiple same services provided on same date on ONE claim
  • Use appropriate modifier to avoid duplicate denials (e.g., 50, RT, LT)
  • When resubmitting services initially rejected (message code MA130), DO NOT include services that were previously paid
    • For example: A claim is submitted with three line items. Two of the services are paid; one is rejected because the CPT code was invalid. When resubmitting a new claim with the corrected CPT code, do not include the two services previously paid, as they will deny as duplicate.
33,091 Code Submitted for Reporting Purposes Only

Some providers are REQUIRED to participate in quality reporting programs. One method of participating is to submit non-payable measures on claims along with payable CPT codes. The non-payable codes are captured by CMS or our processing system to determine whether the provider successfully reported. Initiatives in place include:

NOTE: Because reporting is a requirement, this denial is not one that can be avoided.
30,798 Payment is Included in Another Service Previously Adjudicated
  • Check definition of CPT/HCPCS codes to determine whether the code can be separately billed
  • Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services
  • The status of some CPT/HCPCS codes prevent them for being separately paid
    • Services with a status 'B' are always bundled, as payment is included in other services
19,163 Patient is Enrolled in Hospice

Patients waive Medicare Part B payments for professional services related to the terminal prognosis when hospice coverageExternal PDF is selected.

  • Exception for professional services of an independent attending physician not employed by the hospice
    • Submit service with HCPCS modifier GV
  • Services unrelated to terminal prognosis may be reimbursed
    • Submit service with HCPCS modifier GW

Allow front-office staff access to myCGS to verify patient eligibilityPDF

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