Denial Code CO 6

The CPT-Code/revenue-code doesn’t match the patient’s age. Denial Code CO 6 arises when the discrepancies between the CPT codes/revenue codes and the patient’s age

In medical billing, procedure codes play a crucial role in accurately representing the services provided to patients. Certain procedure codes are defined based on the age of the patient, ensuring that healthcare providers can deliver appropriate and targeted care for different age groups. However, an essential aspect of medical billing is ensuring that the procedure codes billed align with the actual age of the patient to avoid potential denials of reimbursement from insurance companies.

When medical providers submit claims with procedure codes that are designated for specific age groups but do not match the actual age of the patient, it can lead to insurance denials with denial code CO 6. This denial code signifies a discrepancy between the billed procedure code’s age specifications and the patient’s actual age, indicating a mismatch that can result in the rejection of reimbursement by the insurance company.

For examples:

Example 1: Mismatching procedure codes with a patient’s age in critical care services can lead to claim denials, specifically with denial code CO 6, indicating age-procedure code discrepancy. Neonatal critical care services are coded with 99468-99469, while pediatric critical care codes range from 99471-99472 and 99475-99476 for infants or children up to 6 years old. Using incorrect procedure codes for a patient’s age can result in claim denials due to coding inaccuracies. It is crucial for coding teams to adhere to accurate coding practices to ensure proper reimbursement and prevent claim denials.

Let us consider another example:

Example 2: Patient age is 17 years 11 months and provider billed the Procedure code 99385 to insurance company for reimbursement, now insurance company denied the claim with the denial code CO 6 indicating the procedure code 99385 is inconsistent with the patient’s age.

The denial of claim with denial code CO 6, indicating inconsistency between the procedure code 99385 and the patient’s age of 17 years 11 months, highlights a common issue in medical billing and coding. Procedure code 99385 corresponds to a comprehensive preventive medicine examination for a new patient aged 18-39 years. In this case, the patient falls within the age range specified for this procedure code but is marginally below the lower limit by a matter of days, which triggered the denial.

Example 3: In the healthcare industry, HCPCS code Q4039 is specifically designated for patients who are 10 years of age and younger. This code is intended to be utilized for medical procedures performed on pediatric patients within this age range. However, if a healthcare provider incorrectly assigns the procedure code Q4039 for a patient who is 11 years of age, it may lead to insurance claim denials by the insurance company. Denial code CO 6 is commonly associated with this type of error, indicating that the procedure code does not match the patient’s age criteria as per the insurance policy guidelines.

When coding age-related diagnoses, it is crucial for the coding team to exercise caution to prevent the occurrence of denial code CO 6. This denial code typically signifies that the age on the claim does not correspond with the diagnosis code submitted. To avoid such denials, coders must adhere to key coding principles and guidelines.

To address the denial code CO 6, the following actions should be taken:

• Check the payment history to ensure same procedure code previously billed and paid. If yes, then we need to send the claim to reprocess by referencing the previously paid procedure code. If no, then follow the next step.           
• Verify the age appropriateness of a billed procedure code, the first step is to refer to the Current Procedural Terminology (CPT) manual. Each procedure code in the CPT manual includes guidelines regarding the age range for which the procedure is considered appropriate. These guidelines are crucial in ensuring accurate billing practices and adherence to medical standards. In case of discrepancies in the patient’s age, it is essential to cross-reference the age provided in the billing system with the patient’s official records, such as their medical history or identification documents. Incorrectly entered patient age can lead to billing errors and potential claim denials.
• If the age entered is correct in the billing system, then assign the claim to the coding team for review and validation of the CPT code. If the coding team confirms that the procedure code billed is correct but the insurance company denies it incorrectly, the next step is to send the claim back for reprocessing. If a representative disagrees with the coding team’s assessment, it is important to take further action by appealing the claim along with providing supporting medical records.
• If coding team responds with the correct procedure code, it is essential to update the claim with the accurate information and resubmit it as corrected claim for reimbursement..

To prevent denial code 6 and ensure successful reimbursement, healthcare providers must diligently review and verify that the procedure codes billed accurately reflect the patient’s age and the services rendered. Implementing robust processes for double-checking the alignment of procedure codes with patient demographics can help minimize errors and discrepancies that could lead to claim denials.