CO-222 denial code
Exceeds the contracted maximum number of hours, days or units for this period
How to fix it
Confirm the cap and whether an exception process exists. Appeal with medical necessity where one does.
How to prevent it
Track contractual caps per patient per period for services delivered in courses.
In practice
A behavioural health practice provides weekly therapy to a patient throughout the year. In November, claims begin returning CO-222: the contracted maximum number of units for the period has been exceeded.
The plan's contract caps this service at a set number of sessions per calendar year. The cap was reached in October, and every session since has been delivered against a limit that was already spent.
Where the plan operates an exception process, continued medical necessity documentation may extend it. Where it does not, the sessions are not payable — and whether they are billable to the patient depends on whether they were told before the cap was reached, not after.
What sits behind it
CO-222 differs from CO-119 in a way that determines who bears the loss. CO-119 is a benefit maximum in the patient's plan. CO-222 is a limit in the provider's contract with the payer, which usually means the provider absorbs it rather than transferring it to the patient.
The services affected are the ones delivered in courses over time — therapy, chiropractic, behavioural health, infusion, home health. All accumulate quietly against an annual or per-period cap that is recorded in a contract document rather than in the eligibility response.
The prevention is a counter per patient per period per service, checked at scheduling. That sounds heavier than it is, and the alternative is worse: the practice discovers the cap by delivering care past it, usually late in the year when the patient most needs continuity and has least warning that it is about to stop.
Related codes
Terms used here — Prior Authorization · Contractual Adjustment · Patient Responsibility
How we handle it — Prior Authorization · Practice Analytics · Denial Management
Primary sources
The rules behind CO-222, at the bodies that publish them.
- Medically Unlikely Edits (MUE) tables (opens in a new tab)
Centers for Medicare & Medicaid Services — The maximum units of a code payable for one patient on one day. Unit-based denials usually trace to this table rather than to a coding error.
- Medicare Coverage Database (LCD/NCD) (opens in a new tab)
Centers for Medicare & Medicaid Services — Searchable national and local coverage determinations. The direct answer to whether a diagnosis supports medical necessity for a given procedure.
- Medicare Claims Processing Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — The operative manual for how Medicare claims must be coded, submitted, adjusted and appealed. When a payer policy and a vendor's advice disagree, this settles it.
Every denial code with a guide
Authorization
Bundling
Contractual
- CO-45A Contractual Adjustment
- CO-253Sequestration Reduction
- CO-147Contracted Rate Expired
- CO-222Contracted Unit Cap Exceeded
Coverage
Data quality
Documentation
Eligibility
Liability and workers comp
Patient responsibility
Provider eligibility
Timely filing
Looking for a different code? Search all 190 CARC and RARC codes
Questions about CO-222
CO-119 is a benefit maximum in the patient's plan. CO-222 is a cap in the provider's contract with the payer. The distinction determines who absorbs the cost — a contractual cap generally cannot be transferred to the patient.
Sometimes. Some contracts include an exception process where continued medical necessity is documented. Where none exists, the additional services are simply not payable under the agreement.
Usually not, and never retroactively. Where the contract permits it at all, it requires the patient to have been informed in writing before the capped services were delivered.
Track units per patient per period per service and check the count at scheduling. Contractual caps are recorded in the contract rather than in the eligibility response, so nothing in the normal verification workflow will surface them.
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