Medical claim denials are a pain for hospitals and healthcare providers. They add to employees’ work and significantly disrupt the entire revenue cycle.
According to AHIMA, almost 20% of all submitted claims are rejected. That is a toll on healthcare practices’ finances. Plus, as many as 60% of returned claims are never resubmitted, which further adds to the losses. Among the most common codes issued by insurance payers is the CO 18 denial code.
However, even though the CO 18 code is common, it can be prevented. In this blog, we will provide a detailed CO 18 denial code description, methods to mitigate it, and how you can resolve it if you get it from an insurance payer. So, let’s start.
CO 18 Denial Code Description
In short, CO 18 is a duplicate submission denial code. The insurer sends the denial code CO 18 when it receives a claim that matches a previously submitted one in key details.
The insurance company can process this duplicate claim, but in most cases, it chooses not to process it. This is because duplicate claims waste resources, delay payments, and could tarnish the reputation of both the insurer and the healthcare provider.
An insurance company will consider a claim duplicate and send the denial code 18 when it finds any of the following similarities between two submitted claims:
- CPT codes: Procedure codes that describe the medical services provided.
- Service type, date, and location: Overlapping details indicate the same service was billed twice.
- Provider and patient information: Repeating identical details can trigger a duplicate flag.
- Billed amount: Claims with the same payment request amount.
To make things more clear, let’s look at an example.
Consider a scenario where a patient took an imaging service. Let’s say he got an MRI scan at the same facility twice in one day. Now, the insurer might send back the second claim with a duplicate CO 18 denial code if the medical coder at the hospital submits two separate insurance claims for these services due to a lack of communication or any other reason.
What Causes the CO 18 Denial Code?
Now that we have defined denial code 18, let’s discuss the common reasons why it occurs before moving on to prevention and resolution.
Human Error
The most basic and also the most common reason for CO 18 denial is human error. Simple mistakes like re-entering data without verifying prior submissions lead to the rejection. The resubmission can also occur due to some system glitch, which can automatically submit a claim twice.
Billing Errors
Another common cause for this type of denial is a mistake in medical coding. Incorrect coding or incomplete information can lead to claims being flagged as duplicates.
For example, if a coder puts the wrong patient information in the form or uses the wrong modifiers, code 18 denials will be triggered.
Lack of Coordination
As discussed in the example above, lack of communication between the staff is also a cause of denial 18. Let’s look at two scenarios to understand it more simply:
- Multiple departments submit claims for the same service without checking.
- Providers failing to update colleagues about previously billed services.
Software or System Issues
This one is self-explanatory and challenging to prevent. Technical problems such as software errors or system updates can cause unintentional duplicate claim submissions.
Errors During Resubmission
Providers may inadvertently resubmit a claim without resolving the initial issue. Insurance companies interpret this as a duplicate submission.
You see, how just small mistakes and negligence can cause huge financial losses? That is why it is imperative to prevent these types of issues from happening.
How to Prevent Denial Code CO 18?
Now that we know the root causes of the denial code 18, we can discuss the prevention methods.
Create A Strong Documentation and Communication System
Since most of the claim rejections are merely because of a lack of communication and a standardized documentation system, it is imperative to put these systems in place.
As a healthcare provider, you should always:
- Maintain detailed patient records, including service dates, procedures, and any updates.
- Record changes in the treatment plan to differentiate services from previously submitted claims.
Plus, you should hold regular interdepartmental meetings to create a more collaborative environment. Another way to boost communication is to use a centralized software system where all billers and coders from all departments can access all the information simultaneously.
Invest in Staff Training
You should focus on training your billers and coders more than anything. Try to help your employees to get various training and certifications. Also, it is essential to keep up with the continuous changes in the regulations and coding systems. All medical coders in your organization must know:
- Proper use of CPT codes and modifiers.
- Guidelines for verifying patient and service information.
Adopt Advanced Claims Management Systems
If you are still relying on manual and outdated methods to bill your claims, then it is futile to improve on other aspects. The use of technology is essential to reduce the CO 18 denial codes.
Invest in getting computer-assisted coding (CAC) systems. These systems can significantly reduce the human error factor and boost your success ratio.
How to Resolve Denial Code CO 18?
Even after implementing all the precautionary measures, you can sometimes get the denial code 18. So, how can you resolve and resubmit the claim?
Here is how you can do it.
Review the Denied Claim
The first step in resolving the CO 18 denial is to find out why an insurance provider rejected the claim.
To find the claim adjustment reason, you can check the Remittance Advice (RA) sent to you by the insurance company, or to get more details, you can ask the patient to provide his/her explanation of benefits. These documents will outline the reason for the denial and help you identify the duplication.
Verify Original Claims
After checking the rejection reason, compare the original claim with the denied one. Look for overlaps in:
- Service dates and types.
- Patient information and CPT codes.
This will give you a good idea about the root cause and the department where things went wrong. The reasons can be anything from human error during data entry to technical issues causing repeated submissions.
Correct the Errors
If discrepancies are found, correct them promptly. This may involve the following:
- Updating patient or service details.
- Adjusting incorrect codes or modifiers.
Provide Supporting Documentation
Now, before resubmitting, you have to make your case stronger. To validate your claim, you can attach additional documents with your claim request. Documents can include treatment notes or medical records. You can also attach communication logs to demonstrate the necessity of the service or procedure.
Resubmit the Claim
Once all the corrections are made and everything is ready to go, resubmit the claim through the appropriate channels. Double-check all details before submission to prevent further denials.
Appeal if Necessary
If you think the insurance payer has made a mistake in rejecting the first claim request, you can always appeal your case to them. Ensure your appeal includes:
- A clear explanation of why the claim is valid.
- Supporting documentation to back your case.
Final Word
The CO 18 denial code is a reminder for healthcare providers that communication, attention, and maintaining the work standard are essential. Negligence and minor errors during coding can cause substantial financial losses for the organization.
By applying the preventive measures and resolution steps in this blog, you can keep yourself safe from the pitfalls. However, managing denials can be time-consuming and complex. That is why it is recommended to outsource your billing and coding processes to specialized medical billing companies.
You can consult our certified medical billers and coders for expert denial management services. Our experts have decades of experience and can handle all types of denials in medical billing.
