CO5 denial code description and corrective action

• This denial occurs when the procedure code billed is not compatible with the place of service reported on the claim.

• For example, if we bill a procedure code that is meant only for outpatient services, such as 99213, but use POS 21 (which is specifically for inpatient services), the claim will be denied with CO5 because the CPT code and the place of service do not align with each other.

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer.

• The first and most important step is to determine whether the claim denial is valid or if the insurance has denied the claim by mistake.

• Call the insurance company, if claims in the member’s history with the same coding (CPT, POS combination) have been paid, and ask the representative to reprocess the claim. Be sure to note the claim number, rep name and call reference number, and then follow up on the claim after the provided TAT.

• If rep provide correct POS then we'll submit corrective claim.

• Consult coding specialists or use reliable websites to determine whether the procedure and place of service combination used is accurate or not.

• If the coding team confirms that the combination is correct, then we proceed with submitting an appeal.

• For submitting an appeal, we must calculate the timely filing limit starting from the processed date. If the limit has been exceeded, the claim will be denied again for exceeding the filing deadline. In such cases, we should consult with the provider. Some clients may still want us to submit the appeal even after the timely filing limit has passed, so we should proceed according to their instructions.

• If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct POS).

• Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.

Description