CO B16 denial code
Claim adjustment reason code B16. Often reported as CO B16.
New patient criteria not met
Unofficial reference. This is our own plain-English explanation, not the official code text. Payer rules differ. Verify with the payer and the official X12 code list. AlphaPrefix is not affiliated with X12, CMS or any payer. Data last updated .
What B16 means
A new patient visit was billed, but the payer's records show the patient does not qualify as new to this provider.
New patient visit codes usually pay more than established patient codes. Payers generally treat a patient as established when the same provider, or one of the same specialty in the same group, has seen them within a set look back period.
B16 means the payer found such prior care. The usual fix is to rebill using the matching established patient code.
Group codes seen with B16
On a remittance, B16 comes after a group code. These are the ones it is most often reported with:
- CO B16 (Contractual Obligation): The provider's side of the ledger. The reduction comes from the payer contract or a rule the provider has to follow, and the patient normally cannot be billed for it.
The payer chooses the group code for each adjustment, so the same reason code can appear with another group code on your remittance. Read the two together. More about group codes.
Common causes
- The patient saw the same provider or another provider of the same specialty in the group within the look back period.
- The provider changed groups and the patient was seen at the prior practice.
- Staff selected a new patient code by default for a patient seen before.
What to do next
- Check the patient's visit history with the provider and group in your system.
- Rebill with the matching established patient visit code if the patient was not new.
- Appeal with proof if the patient had no qualifying visit within the payer's look back period.
Related codes
- B14 (reason code) One visit per physician per day
- 4 (reason code) Procedure code and modifier do not match
- 16 (reason code) Missing information or billing error
Source
Official wording: X12 Claim Adjustment Reason Codes list. The explanation on this page is our own plain-English wording, not the X12 text.
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