Question

Analyze each of the following denials and determine which prefix (CO or PR) and which reason code you’d receive on a remit.

1. Patient has a service performed and the entire amount is considered deductible __________
2. Patient indicates his name is Jimmy Smith and his insurance number is XZA1234. His insurance has him listed as James Smith ______________
3. A hemoglobin and complete blood count are performed (includes hemoglobin) ___________
4. Patient has music therapy for headaches. The insurance denies stating it’s not a proven effective treatment _______________
5. An EKG was billed for 12/1. The patient dies at 11:58PM 11/30. _____________
6. Patient has repeat Pap Smear due to abnormal cells. ABN signed but no GY modifier was added to the claim. _______________

Answer 1

Denials	Prefix	Reason code
Deductible	PR	1
Patient name	PR	140
CBC & Hemoglobin	CO	97
Music Therapy	CO	56
EKG	CO	13
Pap smear – Modifier	CO	4

Prefix CO stands for contractual obligation – this prefix will be used when the provider has not claimed as per the contractual agreement or coding guidelines.

Prefix PR stands for patient responsibility – this prefix will be used when there is deductible and copayment which is the patient responsibility to pay.