Denial Code 06

Denial Code 05 Denial Code 07

Definition:

The procedure/revenue code is inconsistent with the patient’s age.

What is denial code 06?

Denial Code 06 is issued when a CPT, HCPCS, or revenue code is billed for a patient whose age does not match the clinical appropriateness or coding rules for that service. Certain procedures, screenings, and diagnoses are age-specific, especially for pediatrics and geriatrics. This denial is typically triggered by system edits that match code logic to patient demographics.
Incorrect DOB entry, billing inappropriate services for a patient’s age group, or failing to use age-specific variants of a code can lead to this denial.

Practical Examples

Example 1#

Scenario:
A provider submitted a claim for CPT 99392 (Periodic preventive visit, established patient, age 1–4 years) for a 68-year-old patient with diagnosis code Z00.00, the procedure code was not age-appropriate.
The claim was denied by the payer with denial code 06 along with remark code N130
Remark Code N130 – "Consult plan benefit documents/guidelines for information about restrictions for this service."

Let's break down the issue:
Denial code 06 indicates that the CPT code is not compatible with the patient's age.
CPT 99392 is specifically defined for children aged 1–4.
A 68-year-old patient should be billed with CPT 99397 (Preventive visit for established patient, age 65 and over).
N130 reinforces the need to consult plan guidelines, which usually align with CPT age restrictions.

Resolution:
Confirm the patient’s age and select the correct preventive CPT code for adults. In this case, replace 99392 with 99397. Resubmit the corrected claim for reimbursement.

Example 2#

Scenario:
A pediatric clinic billed CPT 99385 (Initial comprehensive preventive medicine evaluation for ages 18–39, new patient) for a 10-year-old child covered under Blue Cross Blue Shield (BCBS).
The claim was denied with denial code 06 due to the age mismatch between the CPT code and the patient’s actual age.

Let's break down the issue:
Denial code 06 clearly applies because CPT 99385 is defined for adult patients aged 18–39.
The patient is only 10 years old, and the correct CPT code for that age range would be 99383 (initial preventive visit for ages 5–11).

Resolution:
Review the patient’s demographics and confirm the age at the time of service. Replace CPT 99385 with CPT 99383 to accurately reflect a preventive service for a 10-year-old. Resubmit the corrected claim to BCBS.

Why Does Denial code 06 Occur?

1. Procedure Code Not Meant for Patient's Age: Some procedure or revenue codes are only allowed for certain age groups. For example, a code for a newborn screening should not be used for a 30-year-old. If the code doesn’t match the patient’s age, the claim can be denied.
2. Patient’s Age Doesn’t Match Code Guidelines: The patient's age on the claim must fit the official age range allowed for the billed service. If the age falls outside the allowed range (like billing a pediatric vaccine for an adult), the payer will deny the claim.
3. Data Entry Error: The billing team might have selected the wrong code that isn’t age-appropriate, simply by mistake. This can happen due to similar code numbers or manual entry errors.
4. Missing Documentation: Sometimes, the claim may be valid for a rare exception, but if you don’t include medical records to explain why that code was used for that patient’s age, the insurer won’t approve it.
5. Insurance Policy Age Rules: Some payers have their own rules about what procedures are covered at what ages. Even if the code itself allows it, the insurance plan might deny it if their internal policy says it's not medically necessary for that age group.

How to avoid / ways to mitigate Denial code 06?

1. Verify the Patient’s Age is Correct: Always double-check the patient's date of birth in your system. If there’s a typo or outdated info, correct it right away—this simple step can prevent age mismatches.
2. Review Patient Records Carefully: Make sure the procedure or revenue code matches what’s written in the patient’s chart. If the service isn’t appropriate for that age, update the code or explain it with extra documentation.
3. Improve Team Communication: Encourage clear communication between the billing team and healthcare providers. When both teams understand how age affects coding, it helps avoid simple mistakes.
4. Perform Regular Audits: Regularly review submitted claims to find and fix any age-related coding errors. Catching issues early helps reduce denials and keeps claim accuracy high.
5. Train Your Team: Educate coders and billers about how certain codes are age-specific. Provide training sessions whenever guidelines or payer policies change.
6. Use Helpful Technology: Invest in tools like electronic health records (EHRs) or coding software that can alert staff if a code doesn’t fit the patient’s age. These systems can prevent human error before a claim is submitted.
7. Create Age-Based Coding Rules: Set clear internal guidelines for coding procedures that depend on patient age. Share these with your team and ensure they’re consistently followed.
8. Communicate with Payers: Talk to insurance companies to understand their specific rules for age-based procedures. Good payer relationships help resolve issues quickly and avoid repeated denials.

Denial Code 05 Denial Code 07