Denial Code 60 (CARC) means that charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Below you can find the description, common reasons for denial code 60, next steps, how to avoid it, and examples.
2. Description
Denial Code 60 is a Claim Adjustment Reason Code (CARC) and is described as ‘Outpatient Services Not Covered When Performed Before/After Inpatient Services’. This denial code indicates that the insurance company will not provide coverage for outpatient services that are performed within a specific timeframe before or after inpatient services. The exact timeframe may vary depending on the insurance policy and the specific circumstances of the claim.
2. Common Reasons
The most common reasons for denial code 60 are:
- Lack of Coordination of Care: Denial code 60 often occurs when there is a lack of coordination between outpatient and inpatient services. If the outpatient services are performed too close in time to the inpatient services, the insurance company may consider them to be part of the same episode of care and deny coverage for the outpatient services.
- Incorrect Billing Sequence: In some cases, denial code 60 may occur due to errors in the billing sequence. If the outpatient services are billed before the inpatient services, the insurance company may deny coverage for the outpatient services.
- Missing or Incomplete Documentation: Insufficient documentation that clearly demonstrates the medical necessity and separate nature of the outpatient services may result in denial code 60. Without proper documentation, the insurance company may consider the outpatient services to be part of the inpatient services and deny coverage.
- Policy Limitations: Some insurance policies have specific limitations on coverage for outpatient services performed before or after inpatient services. If the services fall within these limitations, denial code 60 may be applied.
3. Next Steps
You can address denial code 60 by taking the following steps:
- Review the Billing Sequence: Double-check the order in which the outpatient and inpatient services were billed. If the outpatient services were billed before the inpatient services, consider resubmitting the claim with the correct billing sequence.
- Coordinate Care: Ensure that there is proper coordination between the outpatient and inpatient services. Communicate with the healthcare providers involved to ensure that the timing of the services aligns with the insurance company’s requirements.
- Provide Sufficient Documentation: Make sure that the documentation clearly demonstrates the medical necessity and separate nature of the outpatient services. Include any relevant medical records, test results, or physician notes that support the need for the services and establish their distinctiveness from the inpatient services.
- Appeal the Denial: If you believe that the denial was incorrect or unjustified, consider appealing the denial. Gather any additional supporting documentation or information that can strengthen your case and present it in your appeal.
- Seek Clarification from the Insurance Company: If you are unsure about the specific policy limitations or requirements related to denial code 60, reach out to the insurance company for clarification. Understanding their guidelines can help you avoid future denials.
4. How To Avoid It
To prevent denial code 60 in the future, consider the following strategies:
- Coordinate Care: Ensure that there is proper coordination between outpatient and inpatient services. Communicate with the healthcare providers involved to ensure that the timing of the services aligns with the insurance company’s requirements.
- Review Policy Limitations: Familiarize yourself with the specific limitations on coverage for outpatient services performed before or after inpatient services outlined in the insurance policies you work with. This knowledge will help you determine whether the services fall within the allowed timeframe.
- Document Medical Necessity: Provide thorough documentation that clearly demonstrates the medical necessity and separate nature of the outpatient services. Include any relevant medical records, test results, or physician notes that support the need for the services and establish their distinctiveness from the inpatient services.
- Verify Coverage: Before performing any outpatient services, verify the patient’s insurance coverage and check for any specific requirements or limitations related to denial code 60. This will help you determine whether the services will be covered and avoid potential denials.
5. Example Cases
Below are two examples of denial code 60:
- Example 1: A patient undergoes a surgical procedure that requires an overnight hospital stay. The next day, the patient visits the same healthcare provider for a follow-up consultation. If the outpatient consultation is billed as a separate service within a specific timeframe after the inpatient procedure, it may be denied under denial code 60.
- Example 2: A patient receives inpatient treatment for a serious illness. After being discharged from the hospital, the patient requires ongoing outpatient therapy. If the outpatient therapy is performed within a specific timeframe before the inpatient treatment, it may be denied under denial code 60.
