CARC 189 Active

CO-189: No Specific Procedure Code for Service Billed

TL;DR

Find a more specific code or submit detailed documentation for the unlisted code. Appeal with service descriptions and comparable pricing.

Action
Verify & Resubmit
Who Pays
Provider
Appeal
Yes
Patient Impact
None
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does CO-189 Mean?

With CO (Contractual Obligation), the unlisted code denial is the provider's responsibility. Either find a more specific code or provide the required documentation for the unlisted code. If no specific code exists and the service was medically necessary, appeal with detailed documentation.

CARC 189 appears when the claim was submitted with an unlisted procedure code (often ending in 99 for CPT codes) and the payer either believes a more specific code should have been used, or the required supporting documentation for the unlisted code was not included. When providers use unlisted codes, payers typically require a detailed description of the service, an operative report, and comparable procedure pricing to process the claim.

Unlisted codes are legitimate when no specific CPT or HCPCS code exists for the service performed, but they require significantly more documentation than standard codes. The payer cannot determine appropriate reimbursement without understanding exactly what was done and how it compares to other coded procedures.

Common Causes

Cause Frequency
Unlisted or not-otherwise-classified (NOC) procedure code used The claim was submitted with an unlisted/NOC procedure code when a more specific CPT or HCPCS code exists for the service performed Most Common
Missing required documentation for unlisted code When an unlisted procedure code is used, the payer requires a detailed description of the service, operative report, or supporting documentation that was not submitted Most Common
More specific code available but not used A specific CPT or HCPCS code exists for the service performed, but the provider used a generic or unlisted code instead Common
Payer does not reimburse unlisted codes without prior authorization The payer requires prior authorization for unlisted procedure codes and authorization was not obtained Common

How to Resolve

  1. Search for a specific code Check the current CPT/HCPCS code set for a more specific code that describes the service.
  2. Submit comprehensive documentation If the unlisted code is appropriate, include a detailed service description, operative report, comparable procedure codes and pricing, and clinical justification.
  3. Obtain prior authorization If required by the payer, get authorization for the unlisted code before resubmitting.
  4. Appeal if denied again Appeal with evidence that no specific code exists and that the service was medically necessary.
Appeal Guide

Appeal with a detailed description of the service performed, operative report, evidence that no specific code exists, and comparable procedure pricing. Include clinical justification for why the service was medically necessary.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-189:

RARC Description
M20 Missing/incomplete/invalid HCPCS Submit the correct, most specific procedure code or provide detailed documentation for the unlisted code →
M127 Missing/incomplete/invalid documentation Submit a detailed service description, operative report, and comparable pricing with the unlisted code →

How to Prevent CO-189

Also Filed As

The same CARC 189 may appear with different Group Codes:

OA-189 PR-189

Related Denial Codes

CO-181 — Procedure Code Invalid on Date of Service CO-182 — Procedure Modifier Invalid on Date of Service CO-261 — Procedure Inconsistent with Patient History CO-A8 — Ungroupable DRG CO-P9 — No CPT/HCPCS Code Available — P&C Only

Sources

  1. https://www.mdclarity.com/denial-code-carcs
  2. https://x12.org/codes/claim-adjustment-reason-codes
  3. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  4. https://medicaid-documents.dhhs.utah.gov/Documents/pdfs/ClaimDenialCodes.pdf
  5. Codes maintained by X12. Visit x12.org for official definitions.