Denial Code Resolutions

4

The procedure code is inconsistent with the modifier used or a required modifier is missing

11

The diagnosis is inconsistent with the procedure

16

Claim/service lacks information or has submission/billing error(s)

18

Duplicate claim/service

21

ABA Therapy denial code

23

The impact of prior payer(s) adjudication including payments and/or adjustments

29

The time limit for filing has expired

45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

50

These are non-covered services because this is not deemed a 'medical necessity'

85

Patient is not eligible for this service

96

Non-covered charge(s)

97

The benefit for this service is included in the payment/allowance for another service/procedure

98

Benefits suspended - investigation in progress

102

Comprehensive outpatient rehabilitation facility services bundled to home agency

107

The related or qualifying claim/service was not identified on this claim

109

Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor

119

Benefit maximum for this time period or occurrence has been reached

125

Submission/billing error(s). At least one Remark Code must be provided

140

Patient/Insured health identification number and name do not match

149

Lifetime benefit maximum has been reached for this service/benefit category

151

Payment adjusted because the payer deems the information submitted does not support this many/frequency of services

162

Service/procedure was provided at an inappropriate (therapeutic) level

163

Attachment referenced on the claim was not received

171

Payment is denied when performed/billed by this type of provider

177

ABA Therapy denial code

180

The referral/authorization number is missing, invalid, or does not apply to the billed services

185

Rendering provider is not eligible to perform the service billed

189

Not otherwise classified or unlisted procedure code was billed when there is a specific procedure code for this service

197

Precertification/authorization/notification absent

202

Non-covered personal comfort or convenience item

204

This service/equipment/drug is not covered under the patient's current benefit plan

212

Local codes not covered by this payer

234

Behavioral Health denial code

286

Behavioral Health denial code

ABA20

Assessment not comprehensive or current

ABA21

Treatment intensity not justified

ABA22

Behavioral targets not age-appropriate

ABA23

Natural environment training missing

ABA24

Prompt fading procedures inadequate

ABA25

Reinforcement schedule not individualized

ABA26

Crisis management plan missing

ABA27

Peer interaction opportunities insufficient

ABA28

Social skills intervention goals vague

ABA29

Sensory processing needs not addressed

ABA30

Crisis intervention procedures not documented

ABA31

Adaptive behavior assessment incomplete

ABA32

Peer interaction opportunities insufficient

ABA33

Token economy system not individualized

ABA34

Transition planning inadequate

ABA35

Self-advocacy skills not taught

B1

ABA services require comprehensive assessment

B10

Supervision ratio exceeds payor limits

B11

ABA Therapy denial code

B12

Missing autism spectrum disorder diagnosis

B13

ABA Therapy denial code

B15

Treatment plan not updated within required timeframe

B2

Parent training hours not documented

B20

Missing behavioral baseline data

B25

Group session ratios exceed limits

B30

Supervision requirements not met

B35

Data collection insufficient for progress tracking

B40

Generalization goals not addressed

B45

Parent training not documented

B5

Treatment plan lacks measurable goals

B50

Restrictive procedures used without justification

B55

Transition planning inadequate

B60

Social skills programming missing

B65

Adaptive behavior goals not functional

B7

This procedure code is inconsistent with the provider type/specialty

B8

Procedure code modifier inconsistent with provider specialty

B9

Provider specialty requires additional certification for this service

BH10

Behavioral intervention plan not evidence-based

BH100

Mindfulness interventions not utilized

BH105

Exposure therapy not implemented

BH110

Cognitive restructuring inadequate

BH15

Functional behavior assessment incomplete

BH20

Crisis intervention protocols not followed

BH25

Peer support services not utilized

BH26

Anger management techniques not implemented

BH27

Impulse control strategies insufficient

BH28

Sleep hygiene education not provided

BH29

Stress management skills not taught

BH30

Family involvement insufficient

BH31

Mindfulness-based interventions not utilized

BH32

Behavioral activation strategies not implemented

BH33

Exposure therapy not conducted when indicated

BH34

Acceptance and commitment therapy not utilized

BH35

Behavioral goals not measurable

BH40

Environmental modifications not considered

BH45

Medication compliance not monitored

BH50

Skill acquisition programs inadequate

BH55

Behavioral data analysis insufficient

BH60

Community integration planning missing

BH65

Motivation enhancement strategies missing

BH70

Contingency management not utilized

BH75

Social determinants not addressed

BH80

Recovery-oriented services not provided

BH85

Harm reduction strategies not implemented

BH90

Therapeutic relationship not established

BH95

Behavioral activation not included

C15

Holter monitor duration insufficient

C2

Cardiac catheterization not medically necessary

C20

Stress test not clinically indicated

C25

Nuclear imaging without proper indication

C30

Echo guidance billed without documentation

C8

Echocardiogram frequency exceeds guidelines

CARD01

Stress test not indicated

CARD02

Echocardiogram frequency excessive

CARD03

Cardiac catheterization not warranted

CARD04

Holter monitor indication unclear

CARD05

Cardiac rehabilitation not prescribed

CCM01

Multiple chronic conditions not documented

CCM02

Care plan not comprehensive or individualized

CCM03

Patient consent not properly obtained

CCM04

Insufficient time documentation for billing

CCM05

Electronic health record access not available

CCM06

Care coordination activities not documented

CCM07

Medication management inadequate

CCM08

Patient communication requirements not met

CCM09

Care transitions not properly managed

CCM10

Chronic condition monitoring insufficient

CCM11

Provider qualifications not documented

CCM12

Emergency care coordination lacking

CCM13

Specialist referral coordination inadequate

CCM14

Health education not provided

CCM15

Preventive care not integrated

CCM16

Social determinants not addressed

CCM17

Care plan updates not timely

CCM18

Quality measures not tracked

CCM19

Patient engagement strategies insufficient

CCM20

Technology integration not optimized

CCM21

Behavioral health integration missing

CCM22

Pharmacy coordination inadequate

CCM23

Cultural competency not demonstrated

CCM24

Family caregiver support not included

CCM25

Cost-effectiveness not demonstrated

CCM26

Remote monitoring protocols not established

CCM27

Advance directive discussions not documented

CCM28

Nutritional assessment not comprehensive

CCM29

Pain management not integrated

CCM30

Discharge planning not coordinated

CCM31

Care gap identification not systematic

CCM32

Patient portal utilization not promoted

CCM33

Social determinants screening not completed

CCM34

Preventive care reminders not automated

CCM35

Care team communication not documented

CCM36

Risk scoring not updated regularly

CCM37

Emergency department utilization not tracked

CCM38

Specialist communication gaps

CCM39

Patient engagement metrics not measured

CCM40

Population health management not implemented

CO 104

Service not authorized by network provider

CO 107

Multi-specialty denial code

CO 109

Behavioral Health denial code

CO 11

Multi-specialty denial code

CO 119

ABA Therapy denial code

CO 126

Behavioral Health denial code

CO 129

Multi-specialty denial code

CO 13

Multi-specialty denial code

CO 131

Multi-specialty denial code

CO 132

Adjustment due to prior incorrect processing

CO 144

Multi-specialty denial code

CO 146

Multi-specialty denial code

CO 147

Multi-specialty denial code

CO 15

Payment adjusted for assistant surgeon/anesthesia services

CO 150

Multi-specialty denial code

CO 151

Multi-specialty denial code

CO 16

Multi-specialty denial code

CO 163

Multi-specialty denial code

CO 167

Multi-specialty denial code

CO 170

Multi-specialty denial code

CO 171

ABA Therapy denial code

CO 18

Multi-specialty denial code

CO 181

Multi-specialty denial code

CO 182

Procedure not covered when performed in this place of service

CO 183

Multi-specialty denial code

CO 185

Multi-specialty denial code

CO 186

Level of care change adjustment

CO 193

Multi-specialty denial code

CO 196

Hospice denial code

CO 197

Behavioral Health denial code

CO 198

Multi-specialty denial code

CO 200

Multi-specialty denial code

CO 204

Behavioral Health denial code

CO 208

National Provider Identifier invalid or missing

CO 21

No separate payment for services included in allowance

CO 210

Service not separately reimbursable

CO 216

Multi-specialty denial code

CO 22

Multi-specialty denial code

CO 222

Exceeds plan frequency limitations

CO 226

Multi-specialty denial code

CO 23

Multi-specialty denial code

CO 231

Multi-specialty denial code

CO 234

Behavioral Health denial code

CO 236

Multi-specialty denial code

CO 24

Multi-specialty denial code

CO 242

Services not provided by network provider

CO 243

Multi-specialty denial code

CO 246

Non-covered charges for ancillary services

CO 25

Multi-specialty denial code

CO 251

Multi-specialty denial code

CO 252

Multi-specialty denial code

CO 253

Multi-specialty denial code

CO 256

Behavioral Health denial code

CO 26

Multi-specialty denial code

CO 261

Provider specialty not appropriate for service

CO 27

Multi-specialty denial code

CO 272

ABA Therapy denial code

CO 273

Behavioral Health denial code

CO 284

Multi-specialty denial code

CO 286

Multi-specialty denial code

CO 288

Multi-specialty denial code

CO 29

Multi-specialty denial code

CO 297

Benefit maximum reached

CO 299

Multi-specialty denial code

CO 31

Multi-specialty denial code

CO 32

Claim missing required information

CO 39

Multi-specialty denial code

CO 4

Multi-specialty denial code

CO 40

Charges not covered by Medicaid

CO 45

Multi-specialty denial code

CO 46

Missing/invalid authorization number

CO 5

Multi-specialty denial code

CO 50

Multi-specialty denial code

CO 54

Multiple physicians/assistants not covered

CO 55

Multi-specialty denial code

CO 56

Procedure code billed is not correct/valid for date of service

CO 58

Multi-specialty denial code

CO 59

Multi-specialty denial code

CO 6

Multi-specialty denial code

CO 8

Multi-specialty denial code

CO 9

Multi-specialty denial code

CO 95

Multi-specialty denial code

CO 96

Multi-specialty denial code

CO 97

ABA Therapy denial code

CO 98

Multi-specialty denial code

CO A1

Claim denied due to Medicare Secondary Payer

CO B13

ABA Therapy denial code

CO B15

ABA Therapy denial code

CO B16

ABA Therapy denial code

CO B7

ABA Therapy denial code

CO B9

Not covered because patient not enrolled in hospice

CO-100

Payment made to patient/insured/responsible party/employer

CO-101

Predetermination: anticipated payment upon completion of services

CO-102

Major Medical Adjustment

CO-103

Providers not participating in the demonstration project

CO-104

Services not covered under Medicare+Choice plans

CO-105

Tax withholding

CO-106

Medicare beneficiary has not elected to assign benefits

CO-107

The related or qualifying claim/service was not identified on this claim

CO-108

Services not covered for this condition

CO-109

Claim not covered by this payer/contractor

CO-11

Diagnosis code does not justify procedure

CO-110

Billing date predates service date

CO-111

Not covered unless the provider accepts assignment

CO-112

Service not furnished directly to the patient

CO-113

Procedure/product not approved by the Food and Drug Administration

CO-114

Procedure/product has not been approved/cleared by the Centers for Disease Control

CO-115

Upgrade or downgrade of services

CO-116

The advance directive on file does not comply with requirements

CO-117

Transportation is only covered to the closest appropriate facility

CO-118

ESRD network support adjustment

CO-119

Benefit maximum for this time period or occurrence has been reached

CO-120

Patient was admitted as an inpatient on a provisional diagnosis

CO-121

Indemnification adjustment

CO-122

Psychiatric reduction

CO-123

Replacement of prior claim

CO-124

Tertiary payor amount

CO-125

Submission/billing error

CO-126

Deductible

CO-127

Coinsurance amount

CO-128

Copayment amount

CO-129

Prior processing information appears incorrect

CO-130

Claim lacks invoice or statement certifying the actual cost of the lens

CO-131

Claim lacks necessary documentation or orders

CO-132

Adjustment code for mandated federal/state/local withholding

CO-133

The disposition of the claim is pending further review

CO-134

Technical component charges must be billed separately

CO-135

Interim bills cannot be processed

CO-136

Failure to follow prior payer s coverage rules

CO-137

Regulatory surcharges, assessments, allowances or health related taxes

CO-138

Appeal procedures not followed or time limits not met

CO-139

Contracted funding agreement

CO-140

Patient/Insured health identification number and name do not match

CO-141

Claim spans eligible and ineligible periods of coverage

CO-142

Monthly Medicaid patient liability amount

CO-143

Portion of payment deferred

CO-144

Incentive adjustment

CO-145

Premium payment withholding

CO-146

Provider contracted/negotiated rate expired

CO-147

Provider performance program withhold

CO-148

Information from another provider was needed for this claim

CO-149

Lifetime benefit maximum has been reached for this service/benefit category

CO-15

Authorization/certification/notification absent

CO-150

Payer deems the information submitted does not support this level of service

CO-151

Procedure code not consistent with modifier used or required modifier missing

CO-152

Diagnosis was invalid for the date(s) of service reported

CO-153

Service was not ordered by a physician

CO-154

Claim has been forwarded to proper payer/processor for handling

CO-155

Payment adjusted because the claim is incomplete or contains invalid information

CO-156

Claim/service denied/reduced for absence of operative report

CO-157

Service was provided as a result of an act of war

CO-158

Service/equipment was not prescribed by a physician

CO-159

Service is not covered when performed in this place of service

CO-160

Benefits are not available under this plan

CO-161

Provider performance bonus payment

CO-162

State Medicaid plan does not cover this service for the patient age

CO-163

Attachment referenced on the claim was not received

CO-164

Claim/service denied as our records indicate you have not been certified for this service

CO-165

Services provided were not prescribed

CO-166

These services are not covered under the patient benefit plan

CO-167

Diagnosis code does not support medical necessity of the service

CO-168

Service provided prior to coverage effective date

CO-169

Anesthesia not covered for this service

CO-170

Payment denied due to medical review

CO-171

Service does not qualify for payment under our outpatient program

CO-172

Service not covered as patient has not met the required eligibility

CO-173

Service was not prescribed by attending physician

CO-174

Service/procedure requires prior authorization

CO-175

Payment denied because service is excluded on member benefit plan

CO-176

Non-network provider services not covered when network providers are available

CO-177

Service denied as information does not indicate medical appropriateness

CO-178

Service/procedure was not within the scope of the practitioner license

CO-179

Service is considered experimental or investigational

CO-180

Service not medically necessary or does not meet medical criteria

CO-181

Procedure code and diagnosis are inconsistent

CO-182

Provider not eligible to bill for this service

CO-183

Service denied as it does not meet plan guidelines

CO-184

Payment reduced as billed service is included in another service

CO-185

Service performed in inappropriate setting

CO-186

Payment denied due to eligibility

CO-187

Consumer Spending Account payments not allowed for this service

CO-188

Service denied as it was deemed not reasonable and necessary

CO-189

Service not covered as per member certificate

CO-190

Payment made from a different fund

CO-191

Procedure code was added/changed because original was invalid

CO-192

Non-covered days/time

CO-193

Original claim not located for adjustment

CO-194

Anesthesia administered by the operating physician

CO-195

Refund issued to an erroneous priority payer

CO-196

Precertification/authorization/notification absent

CO-197

Precertification/authorization exceeded

CO-198

Duplicate claim/service

CO-199

Voluntary withdrawal of funds from payment

CO-200

Expenses incurred during lapse in coverage

CO-201

Workers Compensation case

CO-202

Non-covered personal comfort or convenience services

CO-203

Discontinued or reduced service

CO-204

This service/equipment/drug is not covered under the patient benefit plan

CO-22

This care may be covered by another payer per coordination of benefits

CO-24

Charges are covered under a capitation agreement/managed care plan

CO-27

Expenses incurred after coverage terminated

CO-31

Patient cannot be located to verify eligibility

CO-32

Our records indicate that this dependent is not an eligible dependent as defined

CO-35

The subscriber and the patient are the same

CO-39

Services denied at the time authorization/pre-certification was declined

CO-42

Charges exceed your contracted/legislated fee arrangement

CO-44

Prompt pay discount taken

CO-49

These are non-covered services because this is a routine exam or screening procedure

CO-53

Services by an immediate relative or member of the same household are not covered

CO-54

Multiple physicians/assistants are not covered in this case

CO-55

Procedure/treatment is deemed experimental/investigational

CO-58

Treatment was deemed by the payer to be medically unnecessary

CO-59

Processed based on multiple or concurrent procedure rules

CO-60

Charges for outpatient services with this diagnosis treated in an inappropriate level of care

CO-61

Penalty for failure to obtain second surgical opinion

CO-62

This service is not covered when performed during the same session/date as a previously processed service

CO-63

A portion of the payment is being withheld pending a review

CO-64

Correction to a prior claim

CO-65

Procedure code was invalid on the date of service

CO-66

Blood deductible has not been met

CO-67

Lifetime reserve days have been exhausted

CO-68

Day outlier amount

CO-69

Day outlier amount has been reduced because the outlier day(s) adjudicated exceeded the maximum number

CO-70

Payment reduced because there is no certification on file

CO-71

Payment constitutes the full services for this hospitalization

CO-72

The diagnosis is inconsistent with the patient's age

CO-73

Service/equipment was not prescribed by a physician

CO-74

Payer policy precludes payment for this service

CO-75

Prior payer's (or payers') patient responsibility (deductible, coinsurance, copayments) applied to this claim

CO-76

Services not covered under the outpatient benefits

CO-77

Provider performance bonus

CO-78

Non-covered days

CO-79

Exhausted lifetime maximum

CO-80

Patient is not covered under this benefit

CO-81

Services not related to the original injury

CO-82

The initial evaluation/treatment was not conducted by a physician

CO-83

Services not furnished directly and/or under the direct supervision of a physician

CO-84

The presurgical screening/testing was not conducted

CO-85

Patient is not eligible for this service

CO-86

Service was provided by a non-participating provider

CO-87

Transfer to other facility not appropriate

CO-88

Claim processing information was not found in our system

CO-89

Services not covered under the rehabilitation benefits

CO-90

Patient care was transferred to another provider

CO-91

Consult report is missing

CO-92

Claim was denied due to absence of signature

CO-93

Services were performed in an inappropriate setting

CO-94

Payment constitutes payment in full

CO-95

Plan procedures/services must be preauthorized

CO-96

Non-covered charge(s)

CO-97

Patient liability may not exceed charges

CO-98

Benefits exhausted

CO-99

Coordination of Benefits (COB) information was not provided

D1

Dermatology procedure cosmetic

D10

Biopsy and excision same lesion same day

D15

Destruction codes used inappropriately

D20

Photography not medically necessary

D5

Mohs surgery not appropriate

E1

Emergency department visit not emergent

E15

Critical care time not documented

E20

Procedure and E&M same day without modifier

E25

Trauma activation fee not justified

E8

Observation services not justified

G1

Colonoscopy screening interval inappropriate

G15

Colonoscopy incomplete without medical reason

G20

Biopsy specimens inadequate for diagnosis

G25

Conscious sedation billed separately inappropriately

G8

Upper endoscopy not indicated

H1

Patient not homebound

H15

Missing physician face-to-face encounter

H20

Plan of care not physician-certified

H25

Aide services not skilled

H3

Skilled nursing not required

H30

Therapy goals not functional

H7

Frequency of visits not justified

HOS01

Prognosis not terminal within 6 months

HOS02

Inappropriate level of hospice care

HOS03

Lack of physician certification

HOS04

Curative treatment continued inappropriately

HOS05

Plan of care inadequately documented

HOS06

Disease-specific guidelines not met

HOS07

Functional decline not documented

HOS08

Nutritional status decline insufficient

HOS09

Mental status changes not documented

HOS10

Symptom management inadequate

HOS11

Family caregiver support not addressed

HOS12

Spiritual care needs not assessed

HOS13

Bereavement services not planned

HOS14

Volunteer services not utilized

HOS15

Medical equipment not justified

HOS16

Medication management inappropriate

HOS17

Respite care not medically necessary

HOS18

Continuous care criteria not met

HOS19

General inpatient care not justified

HOS20

Interdisciplinary team meetings incomplete

HOS21

Emergency department visits not coordinated

HOS22

Comfort care measures insufficient

HOS23

Disease progression monitoring inadequate

HOS24

Social work assessment missing

HOS25

Nursing assessment frequency inadequate

HOS26

Pain assessment tools not standardized

HOS27

Caregiver education insufficient

HOS28

Advance directive review not conducted

HOS29

Quality of life assessments not performed

HOS30

Cultural preferences not incorporated

HOS31

Durable medical equipment not optimized

HOS32

Home environment assessment incomplete

HOS33

Symptom management protocols not standardized

HOS34

Volunteer coordination inadequate

HOS35

Outcome measures not tracked

HP1

Terminal diagnosis not supported

HP5

Patient pursuing curative treatment

HP8

Revocation not properly documented

L1

Laboratory tests not medically necessary

L12

Genetic testing criteria not met

L20

Panel tests billed as individual components

L25

Reflex testing not properly documented

L30

Point of care testing billed incorrectly

L5

Frequency of testing excessive

M1

Medical necessity not established

M15

Service/procedure requires prior authorization

M20

Missing/incomplete/invalid HCPCS

M25

Service not covered when performed at this place of service

M30

Documentation does not support level of service billed

M45

Modifier usage incorrect or missing

M50

Bundled procedure billed separately

M51

Behavioral Health denial code

M76

Behavioral Health denial code

M80

Home Health denial code

MA04

Home Health denial code

MA63

Home Health denial code

MH1

Intensive outpatient program not justified

MH100

Medication adherence not monitored

MH105

Cognitive assessment not completed

MH110

Vocational rehabilitation not considered

MH12

Group therapy not appropriate

MH20

Psychological testing not medically necessary

MH25

Crisis intervention not documented as crisis

MH26

Substance use screening not completed

MH27

Trauma-informed care principles not applied

MH28

Medication adherence not monitored

MH29

Family therapy not offered when indicated

MH30

Family therapy without identified patient

MH31

Dialectical behavior therapy skills not taught

MH32

Motivational interviewing not employed

MH33

Psychoeducation insufficient

MH34

Relapse prevention planning inadequate

MH35

Peer support services not utilized

MH40

Group therapy size exceeds therapeutic limits

MH45

Medication management not coordinated

MH5

Therapy frequency exceeds medical necessity

MH50

Risk assessment not current

MH55

Discharge planning premature

MH60

Trauma-informed care not implemented

MH65

Substance abuse screening missing

MH70

Cultural competency not demonstrated

MH75

Therapeutic modality not evidence-based

MH80

Comorbid conditions not addressed

MH85

Family therapy component missing

MH90

Psychoeducation not provided

MH95

Relapse prevention plan inadequate

N130

ABA Therapy denial code

N2

EEG monitoring duration excessive

N382

Behavioral Health denial code

N8

Neurostimulator programming frequency high

NEURO01

MRI not clinically indicated

NEURO02

EEG indication not clear

NEURO03

Neuropsychological testing not justified

NEURO04

Botulinum toxin injection frequency excessive

NEURO05

Epilepsy monitoring not indicated

O1

Conservative treatment not attempted

O12

Surgical approach not justified

O20

Arthroscopy converted to open not documented

O25

Hardware removal not medically necessary

O30

Injection procedure billed with office visit

O5

Pre-surgical imaging inadequate

ON1

Chemotherapy regimen not standard

ON15

Supportive care not cancer-related

ON20

Chemotherapy administration time incorrect

ON25

Tumor marker testing frequency excessive

ON30

Genetic counseling not pre-authorized

ON8

PET scan frequency excessive

OP1

Cataract surgery criteria not met

OP15

Visual field testing frequency excessive

OP20

Fundus photography not indicated

OP25

Refractive surgery consultation coded incorrectly

OP8

Retinal imaging frequency excessive

ORTHO01

Conservative treatment not attempted

ORTHO02

Imaging studies insufficient

ORTHO03

Functional limitations not documented

ORTHO04

Surgical urgency not established

ORTHO05

Post-operative care plan incomplete

OT01

Functional goals not specific

OT02

Equipment recommendations not justified

OT03

Cognitive assessment incomplete

OT04

Work hardening program not appropriate

OT05

Home safety evaluation not documented

PR 2

Behavioral Health denial code

PT01

Medical necessity not established

PT02

Treatment plan not individualized

PT03

Progress documentation insufficient

PT04

Skilled therapy not demonstrated

PT05

Frequency and duration not justified

PT1

Therapy cap exceeded without modifier

PT10

Maintenance therapy not covered

PT15

Hot pack/cold pack billed as skilled therapy

PT20

Duplicate therapy services same day

PT25

Therapy notes lack specificity

PT5

Functional improvement not demonstrated

R15

Imaging interpretation incomplete

R2

Advanced imaging not justified

R20

Bilateral imaging billed incorrectly

R25

Professional component billed with technical

R30

Screening imaging coded as diagnostic

R8

Contrast administration not warranted

SA01

Detoxification not medically necessary

SA02

Level of care not appropriate

SA03

Dual diagnosis not addressed

SA04

Urine drug screening insufficient

SA05

Relapse prevention planning inadequate

SA06

Family involvement not documented

SA07

Medication-assisted treatment not considered

SA08

Continuing care plan missing

SA09

Motivational interviewing not utilized

SA10

Group therapy participation insufficient

SA11

Vocational rehabilitation not addressed

SA12

Trauma-informed care not implemented

SA13

Cognitive-behavioral therapy not provided

SA14

Medical clearance not obtained

SA15

Discharge against medical advice inadequately documented

SA16

Substance use history incomplete

SA17

Legal issues not addressed in treatment

SA18

Social support assessment missing

SA19

Harm reduction strategies not implemented

SA20

Psychiatric medication management inadequate

SA21

Financial counseling not provided

SA22

Spiritual care not offered

SA23

Crisis intervention plan not developed

SA24

Educational groups not documented

SA25

Transportation barriers not addressed

SA26

Withdrawal management protocol not followed

SA27

Cognitive restructuring not implemented

SA28

Contingency management not utilized

SA29

Mindfulness-based relapse prevention not taught

SA30

Matrix model not implemented for stimulant use

SA31

Therapeutic community principles not applied

SA32

Seeking safety model not used for trauma

SA33

SMART Recovery principles not offered

SA34

Motivational enhancement therapy not provided

SA35

Community reinforcement approach not utilized

SLP01

Swallowing study not completed

SLP02

Communication goals not functional

SLP03

Cognitive-communication deficits not assessed

SLP04

Voice therapy medical necessity unclear

SLP05

Augmentative communication not justified

U1

Urodynamic studies not indicated

U10

Cystoscopy and injection same session unbundled

U15

Stone analysis billed without stone passage

U20

Catheter insertion/removal same day

U5

Prostate biopsy not warranted