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DocumentationCARC

CO-112 denial code

Service not furnished directly to the patient or not documented

The payer found no record of direct service to the patient.

How to fix it

Produce documentation showing the service was delivered directly. Appeal with the record.

How to prevent it

Ensure services delivered by staff under supervision meet the payer's incident-to or supervision documentation rules.

In practice

A practice bills a service performed by a medical assistant under physician supervision. The payer reviews and returns CO-112, finding no record that the service was furnished directly to the patient by an eligible provider.

Incident-to and supervision rules permit staff to deliver certain services under a physician's billing, but they attach conditions: an established plan of care, the required level of supervision present, and documentation showing both.

The appeal has to show the conditions were met on that date, which usually means producing the supervising physician's presence in the record. Where the note names only the assistant and no supervision is documented, the appeal has nothing to stand on.

What sits behind it

The supervision levels are distinct and frequently confused. General supervision means the service is furnished under the physician's overall direction without requiring presence. Direct supervision requires the physician to be immediately available in the office suite. Personal supervision requires them in the room.

Which level applies is determined per service rather than per practice, and billing a service requiring direct supervision on a day the physician was at another location produces exactly this denial. The schedule becomes evidence in a way most practices do not anticipate.

Telehealth and remote monitoring have complicated this further, since presence has a different meaning when care is delivered at a distance. Practices billing these services should confirm what the payer currently requires rather than relying on rules learned before the delivery model changed.

Related codes

Terms used here — Medical Necessity · E/M Coding · Denial

How we handle it — Medical Coding · Denial Management · Practice Analytics

Primary sources

The rules behind CO-112, at the bodies that publish them.

Looking for a different code? Search all 190 CARC and RARC codes

Questions about CO-112

An established plan of care from the billing physician, evidence that the supervision level required for that service was met on the date, and a note identifying who performed the work. A note naming only the staff member, with no supervising physician recorded, will not survive review.

General supervision means the service is furnished under the physician's overall direction without requiring their presence. Direct supervision requires them immediately available in the office suite. Personal supervision requires them in the room. Which applies is set per service, not per practice.

It can become decisive. Where a service requires direct supervision and the physician was at another location that day, the schedule contradicts the billing, and reviewers do look at it. Aligning what is billed with where supervising physicians actually were prevents the problem.

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