If you are a medical provider who bills Medicare Part B for your services, you may have encountered the CO-170 denial code on your claim. This code means that your payment is adjusted or denied when performed or billed by this type of provider. In other words, Medicare does not cover the item or service you provided or ordered because it is outside your scope of practice or specialty.
This can be frustrating and confusing, especially if you have been providing or ordering the same item or service for a long time without any issues. So why does this happen and what can you do to prevent it?
Possible Reasons for CO-170 Denial Code
There are several possible reasons why Medicare may deny your claim with the CO-170 denial code.
Some of them are:
- You are not enrolled in Medicare or your enrollment information is outdated or incorrect. Medicare requires all providers who perform, refer, or order items or services for Medicare beneficiaries to be enrolled in the program and have their information updated regularly. If you are not enrolled or your information is inaccurate, Medicare will not pay for your services
- You are not credentialed or authorized to provide or order the item or service. Medicare has specific rules and regulations regarding who can provide or order certain items or services for Medicare beneficiaries. For example, only certain types of providers can order laboratory tests or mammograms2. If you are not one of them, Medicare will not pay for your services.
- You are not following the Medicare coverage policies and guidelines. Medicare has specific criteria and conditions for covering certain items or services for Medicare beneficiaries.
For example, some items or services may require prior authorization, medical necessity documentation, frequency limitations, diagnosis codes, modifiers, etc. If you do not follow these policies and guidelines, Medicare will not pay for your services.
How to Avoid CO-170 Denial Code
To avoid getting the CO-170 denial code on your claim, you should take the following steps:
- Check your enrollment status and information with Medicare. Make sure you are enrolled in Medicare and your information is accurate and up-to-date. You can use the Provider Enrollment, Chain, and Ownership System (PECOS) to verify and update your information online.
- Check your credentialing and authorization status with Medicare. Make sure you are credentialed and authorized to provide or order the item or service you are billing for. You can use the Medicare Provider-Supplier Enrollment Status Inquiry Tool (PESIT) to verify your status online
- Check the Medicare coverage policies and guidelines for the item or service you are billing for. Make sure you are following the criteria and conditions for covering the item or service you are billing for. You can use the Medicare Coverage Database (MCD) to find the relevant policies and guidelines online1.
How to Appeal CO-170 Denial Code
If you believe that your claim was denied with the denial code in error, you have the right to appeal the decision.
You should follow these steps to appeal:
- Review the explanation of benefits (EOB) or remittance advice (RA) that you received from Medicare. It will contain the reason for the denial and instructions on how to appeal.
- Gather any supporting documentation that proves that you are eligible to provide or order the item or service and that it meets the Medicare coverage criteria and conditions.
- Submit a written request for redetermination within 120 days of receiving the denial notice. You can use the Redetermination Request Form (CMS-20027) to submit your request online.
- If your request for redetermination is denied, you can request a reconsideration by a Qualified Independent Contractor (QIC) within 180 days of receiving the redetermination notice.
- If your request for reconsideration is denied, you can request a hearing by an Administrative Law Judge (ALJ) within 60 days of receiving the reconsideration notice.
- If your request for hearing is denied, you can request a review by the Medicare Appeals Council (MAC) within 60 days of receiving the hearing notice.
- If your request for review is denied, you can request a judicial review by a federal district court within 60 days of receiving the review notice.
The CO-170 denial code is one of the common types of Medicare Part B claim denials that providers may encounter. It means that your payment is adjusted or denied when performed or billed by this type of provider.