Denial codes · Denial code
CO-272 and PI-272: coverage guidelines were not met
By Javier Alvarez · Updated · 2 min read
| Official description | Coverage/program guidelines were not met. |
|---|---|
| Group code | CO or PI: the provider carries it |
| Common remark code | N386 (decision based on a National Coverage Determination; for MNT, NCD 180.1) |
| Related codes | 96 (non-covered), 50 (not reasonable and necessary), 119 (benefit maximum reached) |
| First check | The referral's diagnosis and the diagnosis order on the claim |
| Fix route | Corrected claim (frequency 7) if miscoded; appeal if the guidelines were met |
CARC 272 is the payer telling you the service is one it covers, just not for this claim as sent. Unlike CO-96, which says the charge is non-covered, 272 points at the rules around coverage: the diagnosis, the referral, the limit. That usually makes it fixable.
What the codes mean
| Part | Meaning |
|---|---|
272 |
Coverage/program guidelines were not met |
CO / PI |
Contractual obligation / payer-initiated reduction: the provider carries the amount; don't bill the patient without a prior written agreement (an ABN for Original Medicare) |
N386 |
Remark code often paired with it: the decision was based on a National Coverage Determination (for MNT, NCD 180.1) |
| Related | 96 (non-covered), 50 (not reasonable and necessary), 119 (benefit maximum reached) |
Why it happens to dietitians
- Non-qualifying diagnosis on a Medicare Advantage claim. MNT is covered for diabetes, chronic kidney disease not on dialysis and the 36 months after a kidney transplant. Obesity, prediabetes or hyperlipidemia alone get 272, 96 or 50. See Medicare MNT coverage.
- No referral on file, or the referring physician isn't on the claim.
- Hours used up for the calendar year (3 hours the first year, 2 after) without a new referral and G0270.
- Commercial plan conditions: prior authorization, a diagnosis list, or a visit cap that wasn't met.
How to fix it
- Check the referral. Is a qualifying diagnosis documented by the referring provider? If yes and you coded something else first, correct the diagnosis order.
- Make sure the referring provider's name and NPI are on the claim (box 17 / loop 2310A).
- If the hour limit was the problem and the physician has since written a new referral for a change in condition, bill the extra time with G0270 (individual) or G0271 (group).
- If the diagnosis truly isn't covered, stop billing MNT to that plan for it. For Medicare patients, use an ABN or a voluntary notice before future visits.
- If you met the guidelines and the payer is wrong, appeal with the referral, the notes and the plan policy.
How to resubmit
A 272 is a processed denial with a payer claim number. To fix data (diagnosis order, referring provider, code), send a corrected claim with frequency code 7 and the original claim number in box 22 / REF*F8. Don't send it as a new claim: it will deny as a duplicate (CARC 18). Send a new claim only when the original was rejected and never got a claim number. For Original Medicare, use the MAC's reopening process for clerical errors; Medicare Advantage plans generally accept frequency 7.
Worked example
Medicare Advantage denial, then correction
| Field | Value |
|---|---|
| Original claim | Dx A: E66.812 · B: N18.31 · Line 97803 × 3 · ptr A |
| 835 adjustment | CO-272, RARC N386 |
| Payer claim number | 0000000000000 (fake) |
| Referral says | CKD stage 3a, not on dialysis; obesity |
| Corrected claim | Dx A: N18.31 · B: E66.812; ptr A,B; referring NPI added |
| Frequency / ref | 7 · original claim number 0000000000000 |
All data in this example is invented for illustration.
For every other code, see the denial code lookup.