CO 70 Denial Code - Understanding & Resolving Adjustments
Code 70 indicates a cost outlier adjustment on a claim, which means the payer has adjusted the payment to account for unusually high costs associated with the services provided. This adjustment is typically made when the cost of care significantly exceeds typical levels for similar services.
Who Pays: Group Code Liability
For code 70, the adjustment is usually applied under the CO group code, meaning it's a contractual write-off and the patient cannot be billed for the difference. The provider absorbs the adjustment as part of the contract terms with the payer.
Why Claims Get Code 70
- The claim involved services that incurred higher-than-usual costs.
- The payer's contract includes a provision for cost outlier adjustments.
- The billed services exceeded cost thresholds set by the payer.
- A high-cost drug or device was used during treatment.
- The claim was flagged for review due to unusual service intensity.
How to Fix & Resubmit
- Verify the contract terms with the payer to confirm the cost outlier adjustment applies.
- Review the claim to ensure all high-cost services were accurately coded and documented.
- Contact the payer to discuss the adjustment if discrepancies are found in the calculation.
- If applicable, ensure that all necessary supporting documentation for high-cost services is submitted.
- Determine if a corrected claim or additional documentation is needed based on payer feedback.
Corrected Claim or Appeal?
For code 70, a formal appeal is usually warranted if the adjustment appears incorrect based on contract terms or if documentation supports a different cost structure. If the adjustment is valid per the contract, a corrected claim is not applicable.
Preventing Future 70 Denials
- Review payer contracts for cost outlier provisions and understand thresholds.
- Ensure accurate and complete documentation for high-cost services is submitted with initial claims.
- Regularly audit claims involving high-cost services to identify potential outlier situations.
- Train billing staff on recognizing services likely to trigger cost outlier adjustments.