How To Fix Denial Code 7 | Common Reasons, Next Steps & How To Avoid It

Denial Code 7 means that the procedure or revenue code billed is inconsistent with the patient’s gender. This denial code indicates that the insurance company will not make the payment for the service because it does not align with the patient’s identified gender. In this article, we will explore the description of Denial Code 7, common reasons for its occurrence, next steps to resolve the denial, how to avoid it in the future, and provide examples of cases.

2. Description

Denial Code 7 is a Claim Adjustment Reason Code (CARC) that signifies an inconsistency between the procedure or revenue code billed and the patient’s gender. This denial code is typically found in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. It indicates that the insurance company will not reimburse the provider for the service rendered because it does not align with the patient’s identified gender.

2. Common Reasons

The most common reasons for Denial Code 7 are:

1. Inaccurate Coding: Denial Code 7 often occurs when there is an error in coding the procedure or revenue code. This can happen if the wrong code is selected or if the code does not align with the patient’s identified gender. It is crucial for healthcare providers to accurately code the services rendered to avoid this denial.
2. Lack of Documentation: Insufficient or missing documentation can also lead to Denial Code 7. If the medical records do not clearly indicate the patient’s identified gender or if there is a lack of supporting documentation for the procedure or service billed, the claim may be denied.
3. Outdated Insurance Policies: Some insurance policies may have outdated or discriminatory language regarding gender-specific procedures. If the insurance policy does not cover certain procedures for individuals of a specific gender, the claim may be denied under Denial Code 7.
4. Incorrect Patient Information: Inaccurate patient information, such as gender identification, in the billing system can result in Denial Code 7. It is essential for healthcare providers to ensure that patient information is up to date and accurately reflects the patient’s identified gender.

3. Next Steps

To resolve Denial Code 7, follow these next steps:

1. Review Coding and Documentation: Carefully review the coding and documentation for the denied claim. Ensure that the procedure or revenue code accurately reflects the service rendered and that the patient’s identified gender is clearly documented in the medical records.
2. Appeal the Denial: If the denial was due to an error in coding or documentation, submit an appeal to the insurance company. Include any additional supporting documentation that clarifies the appropriateness of the procedure or service billed for the patient’s identified gender.
3. Update Patient Information: If the denial was a result of incorrect patient information, update the patient’s gender identification in the billing system. Ensure that the patient’s information is accurate and up to date to avoid future denials under Denial Code 7.
4. Verify Insurance Policies: Review the insurance policies of the patients to ensure that they do not contain outdated or discriminatory language regarding gender-specific procedures. If necessary, communicate with the insurance company to clarify coverage for the specific procedure or service.

4. How To Avoid It

To prevent Denial Code 7 in the future, consider the following steps:

1. Ensure Accurate Coding: Take extra care when coding procedures or revenue codes to ensure accuracy. Double-check that the selected codes align with the patient’s identified gender and the services rendered.
2. Thorough Documentation: Maintain comprehensive and accurate documentation for all procedures and services. Clearly document the patient’s identified gender and provide any necessary supporting documentation to justify the medical necessity of the procedure or service.
3. Stay Updated on Insurance Policies: Regularly review and stay informed about insurance policies, especially regarding gender-specific procedures. Be aware of any changes or updates to ensure that procedures are appropriately covered.
4. Verify Patient Information: Regularly verify and update patient information, including gender identification, in the billing system. Ensure that the information accurately reflects the patient’s identified gender.

5. Example Cases

Here are two examples of Denial Code 7:

• Example 1: A healthcare provider submits a claim for a mammogram for a patient identified as male. The claim is denied under Denial Code 7 because mammograms are typically performed on individuals identified as female.
• Example 2: A provider bills for a prostate-specific antigen (PSA) test for a patient identified as female. The claim is denied under Denial Code 7 because PSA tests are typically performed on individuals identified as male.

Source: Claim Adjustment Reason Codes