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Claim adjustment reason code

CO-272: Coverage or program guidelines not met

CO-272 means: Coverage/program guidelines were not met. The service is covered in principle but this instance did not meet the programme’s conditions.

Read the group code before you act on this

272 is the claim adjustment reason code. The CO in front of it is the group code — a separate field the payer sets on the remittance. The same reason code arrives under different group codes depending on the payer and the situation, and the group code, not the reason code, decides who owes the money.

CO — contractual obligation. You write it off. You may not bill the patient.
PR — patient responsibility. Billable to the patient.
OA — other adjustment, and PI — payer initiated reduction. Neither is patient responsibility.

What causes it

Frequency limit exceeded — the service is covered but not this often
A required prior step not documented, such as a conservative treatment period
Coverage determination criteria not met for the diagnosis billed
A required screening interval not yet elapsed

How to work it

Get the specific guideline that was not met from the payer, in writing where the amount justifies it.
Check the frequency history — a service delivered elsewhere counts, and the practice usually cannot see it.
Where prior conservative treatment exists in the record, appeal with those dates documented.
Where the criteria genuinely were not met, the conversation is with the provider about the pathway, not with the payer.

How to stop it recurring

For services with frequency limits or step requirements, check the history at scheduling. This denial is almost always knowable before the visit.

Who does this work

A prior authorization seat at $1,900 per seat per month works this queue full time, during your business hours, inside your own system. Every call is logged with the payer reference number and the outcome, and every Friday you get it in writing.

What that seat does →

Codes worked the same way

CO-272 is taken back to the authorization. So are these, which is why a queue sorted by recovery route moves faster than one sorted by code number — the same person, in the same system, with the same evidence to hand, clears all of them in one pass.

CO-197 — Prior authorization absent
CO-15 — Authorization number missing
CO-39 — Authorization already refused
N54 — Claim does not match the authorization

Specialties that name this among their costliest

These are specialties whose own worst denials include one of this kind. The line under each is the denial they name, quoted from their page so you can see what the link is based on.

Ambulatory Surgery Centers
Prior authorization obtained for the surgeon but not the facility
Behavioral Health
Authorization units exhausted mid-course without renewal
Urology
Prior authorization missing for advanced imaging
Radiology
Advanced imaging denied for missing prior authorization
Ophthalmology
An injection given after the drug authorization lapsed, or under an authorization written for a different agent than the one actually drawn up that day.
Neurology
Long-term video EEG authorized as an ambulatory home recording but performed as an admission to the epilepsy monitoring unit, so the facility days sit outside the authorization

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time. Source. At 100 denials a month — an illustration, not a measurement of your practice — that is $5,723 a month, or $68,676 a year, in labour alone.

The figure that makes it worth spending: about 90% of initially denied claims are eventually paid. Source. The reason a denial sits is almost never that nobody knows how to work it — it is that nobody has the hours.

Questions

What does denial code CO-272 mean?

Coverage/program guidelines were not met. In plain terms: The service is covered in principle but this instance did not meet the programme’s conditions.

What causes CO-272?

Frequency limit exceeded — the service is covered but not this often. A required prior step not documented, such as a conservative treatment period. Coverage determination criteria not met for the diagnosis billed. A required screening interval not yet elapsed.

How do you fix a CO-272 denial?

Get the specific guideline that was not met from the payer, in writing where the amount justifies it.. Check the frequency history — a service delivered elsewhere counts, and the practice usually cannot see it.. Where prior conservative treatment exists in the record, appeal with those dates documented.. Where the criteria genuinely were not met, the conversation is with the provider about the pathway, not with the payer..

Can CO-272 be prevented?

For services with frequency limits or step requirements, check the history at scheduling. This denial is almost always knowable before the visit.

Is CO-272 the same as PR-272?

Same reason, different group code. The number 272 is the reason: The service is covered in principle but this instance did not meet the programme’s conditions. The prefix says who carries the amount. CO means contractual obligation — the payer says the amount is not billable to anybody, and it is written off unless the denial itself is overturned. PR-272 is the same reason assigned to patient responsibility — the payer says the amount is owed by the patient, and it is billed to them. Read the prefix before the number: it decides whether you appeal, write off, or bill the patient.

What is the difference between CO-272 and CO-273?

CO-272: The service is covered in principle but this instance did not meet the programme’s conditions. CO-273: The service is covered, but this instance went past a programme limit: more visits, units or sessions than the guideline allows. They are different reasons that happen to sit next to each other in the list, and they are worked differently — CO-272 is taken back to the authorization; CO-273 is appealed with clinical documentation.

Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.

Last updated 2026-09-12. This is operational guidance drawn from payer remittance practice, not legal, coding or reimbursement advice. Payer-specific rules vary and change; confirm against the payer’s own policy before acting on a specific claim.

Written by Ibtesam Asif · Last reviewed 2026-09-12

Code descriptions are the standard published text. Everything after them is operational guidance from our own work, and payer policy governs any individual claim.

Other denial codes

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