Medical Billing Denial Coding Interview Q&A
1. What is a denial in medical billing?
A denial is when a health insurance payer refuses to reimburse for a service, procedure, or item. Denials can
be due to errors in coding, documentation issues, lack of medical necessity, or eligibility problems. Handling
denials correctly helps maximize reimbursement and minimize revenue loss.
2. What are the common reasons for medical claim denials?
Common reasons include:
- Incorrect CPT/ICD-10 codes
- Missing or invalid modifiers
- Lack of prior authorization
- Patient eligibility issues
- Medical necessity not met
- Duplicate claims
- Timely filing exceeded
3. How do you resolve a denial due to incorrect coding?
I would review the coding guidelines, payer policies, and clinical documentation. Once the correct code is
identified, Id submit a corrected claim or an appeal with the revised code and supporting documentation.
4. What is a CO-97 denial code, and how would you address it?
CO-97 indicates that a service is included in another billed service (bundling issue). Id check if a modifier
(e.g., -25 or -59) is appropriate to indicate a separate service. If supported, Id rebill with the correct modifier
and documentation.
5. What would you do if a claim is denied as "not medically necessary" (CO-50)?
I would review payer policies (e.g., LCD/NCD), ensure diagnosis codes support the procedure, and check
documentation. If everything aligns, Id file an appeal with medical records and a detailed cover letter
explaining medical necessity.
Medical Billing Denial Coding Interview Q&A
6. How do you avoid claim denials?
- Use coding software and payer-specific edits
- Verify patient eligibility and benefits
- Conduct pre-bill audits
- Educate providers on documentation
- Track denial trends and address root causes
7. How do you handle a CO-18 denial (duplicate claim)?
Id verify whether its a true duplicate or a case of multiple valid services. If valid, Id rebill with correct units or
modifiers and possibly attach supporting documentation to justify separate services.
8. Describe your experience with denial appeals.
Ive written appeal letters, attached supporting medical records, cited payer policies or clinical guidelines, and
followed up within payer timelines. I maintain appeal logs to track outcomes and learn from patterns.
9. What is the difference between a denial and a rejection?
A rejection happens when a claim fails to pass initial scrubbing or payer edits (e.g., invalid NPI, formatting
error). Its never entered into adjudication. A denial is a claim that was processed and explicitly not paid by the
payer. Rejections are corrected and resubmitted; denials often require appeals.
10. What are modifiers -25 and -59 used for, and how can incorrect use lead to denials?
- Modifier -25: Indicates a significant, separately identifiable E/M service on the same day as a procedure.
- Modifier -59: Used to denote distinct procedural services.
Incorrect use (or failure to use them when needed) can lead to bundling denials like CO-97. Proper
documentation must support modifier use.
11. CO-97 Denial Scenario
Denial Code: CO-97 Service included in another procedure.
Scenario: E/M and minor procedure billed together. E/M denied.
Medical Billing Denial Coding Interview Q&A
Answer: Check for separate, significant E/M. Add modifier -25 and rebill with documentation.
12. CO-18 Denial Scenario
Denial Code: CO-18 Duplicate claim/service.
Scenario: Same CPT code billed twice for same DOS.
Answer: Check if duplicate. If justified, use proper units and appeal with records.
13. CO-16 with MA130 Denial Scenario
Denial Code: CO-16 Missing/invalid claim info. Remark: MA130.
Scenario: Diagnosis code missing on outpatient surgery.
Answer: Add missing code and resubmit. Implement checks to catch omissions.
14. CO-50 Denial Scenario
Denial Code: CO-50 Not medically necessary.
Scenario: Diagnostic test denied.
Answer: Review LCD/NCD. If justified, appeal with medical notes and guidelines.
15. PR-204 Denial Scenario
Denial Code: PR-204 Not covered under benefit plan.
Scenario: Custom orthotic denied.
Answer: Verify coverage, notify patient, and confirm ABN was signed if applicable.
16. Steps to Reduce Denials
- Audit claims regularly
- Use correct CPT/ICD-10/modifiers
- Train providers
- Perform eligibility/authorization checks
- Use trends to improve processes
Medical Billing Denial Coding Interview Q&A
17. Corrected Claim Process Example
Scenario: Procedure code denied for missing modifier.
Answer: Apply correct modifier (e.g., -59), review notes, and resubmit as corrected claim.
