CO-272 denial code
Coverage or program guidelines were not met
How to fix it
Identify the specific guideline and whether it can be satisfied.
How to prevent it
Review program guidelines for services with participation conditions before delivering them.
In practice
A practice bills a service under a program requiring specific documentation and participation conditions. One condition was not satisfied, and the claim returns CO-272.
Program requirements sit alongside ordinary coverage rules and have to be met independently. A service can be medically necessary, correctly coded and covered while still failing a program condition.
Identify which guideline was not met, since the code does not say, and establish whether it can still be satisfied. Some conditions are curable after the fact and some are not.
What sits behind it
The programs involved vary widely — diabetes prevention, cardiac rehabilitation, behavioural health integration, chronic care management and others each carry their own participation and documentation requirements that differ from general coverage rules.
The requirements are usually documented in a program manual rather than in the general coverage policy, which is why practices meeting every clinical standard still fail. Reading the manual once for a program you bill regularly prevents a recurring category.
CO-273 is the mirror image and reports guidelines exceeded rather than unmet. Together they mark the boundaries of a program's parameters, and a practice seeing both is operating outside the envelope in two directions at once.
Related codes
Terms used here — Medical Necessity · Prior Authorization · Denial
How we handle it — Denial Management · Prior Authorization · Practice Analytics
Primary sources
The rules behind CO-272, at the bodies that publish them.
- 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 Benefit Policy Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — What Medicare covers and under what conditions, as distinct from how a claim is processed. The starting point for any coverage or medical necessity question.
- Advance Beneficiary Notice of Noncoverage (ABN) (opens in a new tab)
Centers for Medicare & Medicaid Services — The form and the rules for issuing it. Whether a non-covered service can be billed to the patient usually turns on whether a valid ABN was obtained beforehand.
Looking for a different code? Search all 190 CARC and RARC codes
Questions about CO-272
Call the payer or consult the program manual, since the code names no specific condition. The requirements usually live in a program-specific document rather than the general coverage policy, which is why they are easy to miss.
Structured programs with participation conditions — diabetes prevention, cardiac rehabilitation, behavioural health integration and chronic care management among them. Each carries documentation and enrolment requirements separate from ordinary coverage rules.
They mark opposite boundaries of the same envelope. CO-272 means a requirement was not met; CO-273 means a limit was exceeded. Seeing both on the same program suggests the parameters were never fully understood.
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