Denial code · group CO
CO-49: The plan excludes routine checkups and the screening work done as part of them
Short answer
Denial code CO-49 means the payer classed the visit, or a test done alongside it, as routine or screening care that the patient's benefit does not pay for. Often the visit was really problem-oriented and was coded as a checkup, or a Medicare wellness visit went out as a physical. Recode it when the record shows a problem was managed; when it was a true checkup, the exclusion stands.
Look up other codes in the denial code library.
Last reviewed by the Remitwright billing team. Editorial policy
Group CO means contractual obligation: the balance is written off, not billed to the patient. The number is the reason; the two-letter group says who carries the balance.
Remark codes that usually come with CO-49
- N425
- Medicare's governing law leaves this service out of the benefit, so it is not payable
- N130
- The plan's benefit documents set limits on this service; check them for the rule applied
Common causes
A Medicare physical billed as if it were covered
Medicare Part B pays for a Welcome to Medicare preventive visit within the first 12 months and a yearly wellness visit every 12 months after that. Medicare.gov is explicit that the yearly wellness visit is a planning conversation and not a routine physical exam. A preventive medicine physical billed to Medicare for the same patient comes back as routine.
Screening tests linked to the routine exam diagnosis
Labs, an ECG or imaging ordered at the checkup and pointed to the routine exam diagnosis inherit its status. A test ordered because of a symptom or a known condition should point to that diagnosis instead.
A problem was managed but only the checkup was billed
The clinician adjusted a blood pressure medicine or worked up a new complaint during the preventive visit, yet the claim shows only the preventive code. Whatever work went into the problem has no line of its own, and the only line on the claim is routine.
Routine care sent to a medical plan instead of the right benefit
Routine eye exams and some screening services sit in a separate vision or wellness benefit. Sent to the medical plan, they deny as routine even though another payer would have covered them.
How to fix it and resubmit
- 1
Read the note before you touch the codes
Look for a separately documented problem: history, exam and decisions about a condition that would have brought the patient in on its own. That decides between a recode and a write-off.
- 2
Recode problem-oriented work
Bill the problem visit with modifier 25 alongside the preventive service where the payer allows both on one date, and point each line at its own diagnosis. Send a replacement claim and keep the note handy in case the payer asks for it.
- 3
Use Medicare's preventive visits for Medicare patients
Bill the Welcome to Medicare visit or the yearly wellness visit when that is what took place. When a patient asks for a physical anyway, CGS, the Medicare contractor for Kentucky and Ohio, tells providers to submit excluded services with modifier GY if the patient wants a denial to send to a secondary insurer.
- 4
Route routine services to the benefit that pays them
Send routine vision or wellness services to the separate plan named in the eligibility response, with that plan's member ID and its own claim rules.
How to prevent it
- Scheduling scripts that ask Medicare patients whether they want the yearly wellness visit or a physical, and explain the difference before the day
- Charge entry rules that point screening tests to the diagnosis the order names, not automatically to the routine exam code
- Coder review of preventive visits where a problem was also addressed, so the separate work gets its own line
- Eligibility checks that capture vision and wellness benefits alongside the medical plan
An annual physical that was really two visits
A 70-year-old patient books her annual physical with a family practice. The physician completes the yearly wellness visit, then spends part of the visit adjusting her diabetes medicine after a high A1c. The claim goes to Medicare with a single preventive medicine physical code and returns CO-49 with N425. The coder reads the note, replaces the physical with the yearly wellness visit, adds a problem-oriented visit with modifier 25 pointed to diabetes, and sends a replacement claim. The scheduler's template is changed so Medicare patients are booked for the wellness visit by name.
Official text: the X12 claim adjustment reason code list. The meaning above is our paraphrase for billers; the list is the authority.
FAQ
Questions about CO-49
Does Medicare cover an annual physical?
Can I bill the patient for a CO-49?
Why did the lab work from the physical deny too?
How is CO-49 different from CO-204?
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