Billing > Billing
CO-45 denial - getting paid nothing
BWB:
Hello Everyone,
I am very new to medical billing in a small GA podiatry office and need your help. I am getting CO 45 denial codes that I am not getting paid anything for. There are no other denial codes of explanation and the whole claim is effectively denied. My first thought is that maybe the office visit code is too high for the diagnosis, but I just don't know.
Please help
asilva03:
Usually this is not a denial, but that you have billed over the Medicare allowed amount. Is there anything in the other fields like the deductible, etc?
PMRNC:
--- Quote ---I am very new to medical billing in a small GA podiatry office and need your help. I am getting CO 45 denial codes that I am not getting paid anything for. There are no other denial codes of explanation and the whole claim is effectively denied. My first thought is that maybe the office visit code is too high for the diagnosis, but I just don't know.
--- End quote ---
You mention you are very new, you might want to get some further education in regards to Medicare particullarly. C045 is not a denial code, it's an adjustment code (contractual adj) As asilva03 mentioned, if you have zero payments you need to look for deductible and maybe other codes indicated on the bottom of the Medicare EOMB
BWB:
--- Quote from: PMRNC on July 26, 2013, 02:32:03 PM ---
--- Quote ---I am very new to medical billing in a small GA podiatry office and need your help. I am getting CO 45 denial codes that I am not getting paid anything for. There are no other denial codes of explanation and the whole claim is effectively denied. My first thought is that maybe the office visit code is too high for the diagnosis, but I just don't know.
--- End quote ---
You mention you are very new, you might want to get some further education in regards to Medicare particullarly. C045 is not a denial code, it's an adjustment code (contractual adj) As asilva03 mentioned, if you have zero payments you need to look for deductible and maybe other codes indicated on the bottom of the Medicare EOMB
--- End quote ---
There are no other codes and its not the deductible. The co-45 adjustment just wipes out the bill.
RichardP:
Take a look at this link:
http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/
On the right side of the page, note the heading: Claim Adjustment Group Codes . Listed under this heading (after some narrative) are five codes - the first of which is "CO" = Contractual Obligation. Then look at the list of numbers on the left side of the page and find "45" - Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability) . Note that this "45" entry was last modified on 7-01-13.
Note also that insurance carriers do not cover every charge the doctor submits, including Medicare.
Put that all together, we see you are being told that this is a contractual obligation - where the charge exceeds ... contracted/legislated fee arrangement.
The Contractual issues that come to my mind would be these:
1. Provider is not a contracted participating provider. This is not likely the issue, because the EOB should still show payment, but paid to the patient.
2. Carrier does not cover the charge submitted. In this case, nothing would be paid to either the provider or the patient, and the EOB would look as you have described it.
What procedure and diagnosis codes did you submit?
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