CO-11 denial code
The diagnosis on the claim doesn't support the procedure billed, under the payer's rules.
“The diagnosis is inconsistent with the procedure. …”
Start 01/01/1995 · Last modified 07/01/2017 · X12 adjustment reason code list
What it usually means in behavioral health
Common behavioral health versions: a substance use diagnosis on a service the payer covers only for mental health (or the reverse), a Z code or symptom code as the primary diagnosis, or ABA billed without the autism spectrum diagnosis most payers require for it.
Diagnosis order matters too. The diagnosis pointer on each line should point to the condition the service treated.
Common causes
- Primary diagnosis doesn't support the service billed
- A Z code or unspecified code as primary when the payer requires a specific diagnosis
- The diagnosis pointer on the line points at the wrong diagnosis
- Service limited by payer policy to specific diagnoses
Correct and resubmit, or appeal?
If the coding was wrong (order, pointer, or specificity), correct and resubmit. If the payer's policy was misapplied to a correct diagnosis, appeal with the policy and the record.
What to do
Check the diagnosis codes, their order, and each line's pointer against the record.
Check the payer's policy for which diagnoses support the service.
Correct and resubmit, or appeal if the diagnosis was right and the policy supports it.
Often seen with
- N130
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