Getting to the Bottom of “Other Documentation” Denials

By: Ashley Hunter, MBA, CHFP, CRCR, and Briauna Driggers

There is one denial reason code that consistently ranks among the top denied categories in every organization, yet it is rarely discussed. One payer response that no one wants to see is CO-16. This code requires additional effort on the backend to ensure the claim is fully paid. Sometimes, it can feel like a guessing game when trying to interpret what the payer truly requires with this reason code. To prevent “other documentation” denials, organizations must be proactive in identifying the root cause and implementing workflows for future prevention. 

Understanding “Other Documentation” Denials

“Other documentation” denial responses can serve as a catch-all for any denial reason, even those that could have a more specified code established. While all payers utilize CO-16, some issue it more frequently than others. 

The variety of causes can be narrowed down into two primary groupings: ​

• Errors present on a claim
• Additional information requested 

​There is a substantial amount of information on a claim – from patient demographics to procedure and diagnosis codes to physician identification. It is easy to assume that all information will make it to the claim accurately; However, this is far from a simple process and not always the reality. The sources of all information must be considered, meaning a complex combination of all revenue cycle and clinical components is involved. Dealing with a CO-16 denial related to missing or inaccurate claim information is slightly easier than dealing with one requesting additional information. 

A CO-16 denial citing a payer’s request for additional documentation or medical records can be trickier to navigate. It is often difficult to pinpoint the exact piece of information a payer is looking for within clinical documentation to justify payment for the service. Typically, these requests for more information stem from insurance policies that outline what clinical criteria must be met for the service to be covered. Policies can change very frequently and are not always easy to locate, making these denials more common if you are not actively keeping up with all updates. In addition, the policies are lengthy and differ from plan to plan and state to state under the same payer, making the needed information hard to find. 

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Analyzing the Root Cause of “Other Documentation” Denials

Although CO-16 denials are frustrating due to their vague reason code definition, they have one trait that makes it much easier to find the root cause than any other category. With most other denial categories, payers will return one remit code –N381– in addition to the primary denial reason code. Remit code N381 is very generic and directs providers to consult their contractual agreement with the payer. 

For “other documentation” denials, payers will utilize at least one (typically multiple) very descriptive remit codes. These secondary codes are the key for root cause analysis. 

Code	Description
M67	Missing/incomplete/invalid other procedure code(s)
M119	Missing/incomplete/invalid NDC (National Drug Code)
MA60	Missing/incomplete/invalid patient relationship to insured
MA63	Missing/incomplete/invalid principle diagnosis
N4	Missing/incomplete/invalid prior insurance carrier(s) EOB

​These example remit codes showcase potential root causes stemming from every part of the revenue cycle. Determining why your claims are getting denied can help identify the specific documentation or information that the payer is requesting.  For example, if an MA60 (Missing/incomplete/invalid patient relationship to insured) is issued, then the patient’s registration information must be reviewed to confirm their accurate relationship to the subscriber. To prevent future denials for the same reason, the example should be investigated further to determine why the correct information was absent from the claim and ensure proper procedures and workflows are in place for documentation.

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​How to Be Proactive in Preventing “Other Documentation” Denials

​Many organizations often overlook the importance of having a strategy to prevent documentation denials, as they do not consider them critical. Although these denials may not lead to immediate financial losses from write-offs, they can still have a significant financial impact in other ways. For example, for every claim that is denied, someone on staff ultimately has to correct and resubmit the claim. The salary and time spent resolving a claim is part of the total cost to fix a denial. The impact of this type of payer response must also be considered for revenue cycle KPIs. Extended AR days, open denials, and collection rates are all often linked to “other documentation” responses.  

Resolving Claim Content Errors

​Documentation denials related to claim content are easier to navigate because the payer specifies exactly what information the provider needs to supply or correct. An organization should begin by analyzing its CO-16 data to identify any recurring remit codes from a payer that may indicate a common root cause of the inaccuracies in claim information. Once this root cause is identified, the next step of review should be to determine if the claim output is due to human or system errors. Human errors can be addressed through workflow revision and optimization, while system errors will likely involve both related process staff and IT. 

​Example of Resolving Claim Content Errors:
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Problem: An organization consistently receives CO-16 denials with a remit code that indicates a drug’s NDC code is missing.
Process: Upon investigating the root cause, it is found that clinical staff administering the drug are inputting the NDC into a treatment management system, but not the electronic health record (EHR) system. Due to the structure of the interface between the two software systems, the necessary information for accurate claim submission is not being transferred appropriately.
Solution: The organization has very limited IT resources, so they place a ticket to resolve this issue with the understanding that it may take a few months to resolve. To address the issue temporarily, the clinical staff's workflow was adjusted to require inputting the NDC code in both the EHR and the treatment management system.

Satisfying Payer Policies Relating to Documentation Requests

​To avoid additional documentation requests from payers, an organization should proactively identify trends specific to the payer and remark code associated with CO-16 remit codes. For every trend identified, a payer policy should be located and made readily available to staff members reworking denied claims. It is important to ensure that the payer policies are monitored regularly as they change frequently. After linking denied claims to specific payer guidelines, it can be challenging to locate the specific information that the payer requires within clinical records. In some cases, the service provider's office may not even have the records the insurance company is requesting, especially if it pertains to a patient’s history. It is important to consider the source of the required documentation to determine if collaboration is needed with referring provider offices, or if the organization needs to consider process optimization. 

Examples of Collaboration to Satisfy Payer Policy Documentation Requirements:

Requirements of patient history and past services – When a payer requires a patient to have received prior treatments or to have met specific criteria documented by an outside physician, it is important to modify workflows for the staff responsible for registering and scheduling new patients. Their process should include collaboration with referring provider offices to ensure that all necessary documentation is gathered before the patient’s first appointment.

​Service-related required documentation – Sometimes, payers may request that specific information be documented during an encounter for payment purposes. In such cases, an organization can work with the clinical team to ensure that this information is not only captured but also organized in a way that makes it easy to locate.

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Proactive Solutions

​Addressing CO-16 denials and the accompanying documentation issues requires a dedicated approach that combines thorough analysis, proactive strategies, and ongoing education. By understanding the nuances of these denials and their underlying causes, healthcare organizations can implement effective workflows that minimize the occurrence of “other documentation”-related claims issues. Regular training and updates on payer policies, streamlined communication within revenue cycle management, and meticulous review of claims data will not only enhance the precision of submitted information but also improve overall revenue cycle performance. Ultimately, investing in prevention and resolution strategies for CO-16 denials can lead to reduced administrative burdens, improved cash flow, and more efficient patient care processes, making it essential for organizations to prioritize this aspect of their operations.

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