Therapy Denial Codes & Solutions

This guide explains why claims deny and exactly how Med Axis RCM fixes them for Physical Therapy, Occupational Therapy, Speech Therapy, Chiropractic, Behavioral Health & Pediatric Therapy.

Authorization & Coverage Denials

CO-197

Authorization Required / Missing

Applies to: PT, OT, ST, Pediatric Therapy, Behavioral Health

Why it happens

Prior auth not obtained for PT / OT / ST
Auth expired mid-plan of care
Units billed exceed authorized visits

How Med Axis RCM Fixes It

Verifies auth before first visit
Tracks authorized vs used units in real time
Flags expiring auths before denial occurs
Submits retro-auth where payer allows

CO-50

Non-Covered Service

Why it happens

Incorrect CPT for payer policy
Group therapy billed as individual
Modality not covered by plan

How Med Axis RCM Fixes It

Payer-specific CPT mapping
Modifier correction (GP, GO, GN, 59)
Alternate billable code selection
ABN workflow for self-pay transition

Medical Necessity & Diagnosis Mismatch

CO-96

Service Not Consistent With Diagnosis

Why it happens

ICD-10 doesn’t support CPT
Eval billed without functional limitation
Pediatric dx not age-appropriate

How Med Axis RCM Fixes It

Diagnosis-to-procedure cross-check
ICD sequencing (primary vs secondary dx)
Functional deficit documentation alignment
Pediatric ICD validation rules

CO-97

Bundled / Inclusive Service

Why it happens

Manual therapy bundled into ther-ex
Modalities billed incorrectly
Chiropractic manipulation overlapping services

How Med Axis RCM Fixes It

Proper use of modifier-59
Time-based unit recalculation (8-minute rule)
Separate, defensible documentation

Documentation & Coding Errors

CO-151

Incomplete / Missing Documentation

Why it happens

Missing eval
No physician signature
Incomplete progress notes

How Med Axis RCM Fixes It

Pre-submission documentation audit
Provider signature tracking
SOAP note compliance checklist
EMR-specific templates

CO-4

Incorrect Modifier

Why it happens

Missing GP / GO / GN modifier
Modifier-59 misuse
Telehealth modifier errors (95, GT)

How Med Axis RCM Fixes It

Specialty-specific modifier rules
Auto-modifier logic per payer
Modifier validation before submission

Timed Units & Frequency Issues

CO-55

Frequency Exceeded

Why it happens

Visit limits exceeded
Units billed beyond payer cap
Missed medical necessity updates

How Med Axis RCM Fixes It

Visit counter per payer plan
Timely progress report submission
Medical necessity recertification

CO-125

Timely Filing Exceeded

Why it happens

Front-end delays
Clearinghouse rejections not corrected
Staff shortages

How Med Axis RCM Fixes It

Daily claim aging dashboard
Clearinghouse rejection monitoring
24–48 hour claim turnaround SLA

Eligibility & Coordination Issues

CO-22

Coordination of Benefits

Why it happens

Primary vs secondary not updated
Pediatric plans with multiple coverages

How Med Axis RCM Fixes It

Eligibility verification before visit
COB updates prior to submission
Correct payer sequencing

CO-18

Duplicate Claim

Why it happens

Resubmission without frequency code
Auto-posting errors

How Med Axis RCM Fixes It

Claim history check before resubmission
Correct frequency codes (7, 8)
Duplicate scrub rules

Specialty-Specific Denial Triggers (High Value)

Pediatric Therapy

Age-inappropriate ICD codes

Missing developmental delay documentation

Fix: Pediatric ICD validation + milestone justification

Behavioral Health

Time mismatch between CPT & note

Missing diagnosis on initial visit

Fix: Time-based CPT validation + intake audit

Chiropractic

Maintenance care flagged

Excessive frequency

Fix: Active care documentation + re-exam scheduling

“Denials aren’t random — they’re predictable.”

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