Denial Code CO 4

Whenever provider submit/bill the claim with inappropriate/inconsistent/incorrect modifier or bills the claim without a required modifier, then insurance company will deny the claim with denial code CO 4. Denial Code CO 4 indicates the procedure is inconsistent with the modifier used or a required modifier is missing.

What is Modifier?

Modifiers are added to the procedure codes (CPT’s or HCPCS), which gives additional information to the service without changing the service’s original meaning. It is a 2-character numeric or alpha numeric code that are used with procedure codes.

For example:

Consider patient has taken treatment on his left side of the body, so claim should be indicated with LT modifier to indicate the services performed on left side.

In same way if it is on right side, then claim should be reported with RT modifiers

Now suppose the patient receives same treatment on both sides (left and right) on the same day with same provider, then the procedure code should be indicated with 50 modifiers (Bilateral).

Similarly, there are so many modifiers available which gives additional information to the insurance payer for adjudicating the claim.

Resolution for Denial Code CO 4:

Here, we need to illustrate this into two ways to resolve the denial code CO 4:

• Modifier missing
• Inappropriate modifier.

When modifier missing take the following steps:

• When you receive the above denial code, then the very first step is to check the services billed with modifiers or not.
• If services billed without modifier, then check whether billed services require a modifier or not. If it’s required, then add the missing modifier and resubmit the claim as corrected claim.

Example:

Chris suffered a severe crushing injury on his left upper leg. Two days after surgery, Dr James completed a dressing change under general anaesthesia. Provider reported the claim with the procedure code 15852 and found Insurance denied the claim with denial code CO 4.

Upon checking the above example found LT modifier is missing as the service performed on the left upper leg, but provider submitted the claim without a required modifier. In this case we need to add the required modifier LT and resubmit the claim as corrected claim.

15852 – LT

When modifier submitted is inappropriate then take the following steps:

• If services billed with modifier and claim denied with denial code CO 4, then we need to review or check with coding team and verify the modifier billed with CPT is in-appropriate or not.
• If the coding team suggest the modifier billed with CPT is in-appropriate, then add the appropriate modifier and resubmit the claim as corrected claim.
• If suppose the modifier billed with CPT is appropriate, but claim denied with denial code CO 4. In this case reach out insurance claims department and explain the same and send the claim back for reprocessing. If they disagree, then the last option is to appeal the denied claim with supporting documents.

While using the modifiers, coding team should follow the strict coding guidelines to avoid the above denial code CO 4.

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)