RemitBench/Denial codes/CO-273

CO-273 denial code

Code 273 is the twin of 272 and the difference is one word. Exceeded, not unmet. Something has a ceiling and you went past it, and documentation does not usually move a ceiling.

The code list's own wording: Coverage/program guidelines were exceeded.

Why the payer sent it

• A frequency limit: this many per year, per period, per tooth or per quadrant.
• A quantity limit on units for one date.
• A duration limit, where a course of treatment ran longer than the plan covers.
• An age limit on the benefit, which usually arrives with remark N129.
• A programme limit rather than a plan limit, which is why the code says programme.

Remark codes you will see with it

Read the letters in front of the 273

What to do next

1. Ask for the dates behind the count

   Not the total. The list. That is where a duplicate or another provider's claim becomes visible, and those are the two things that make a limit denial wrong.

   If a date is duplicated: reprocessing request with the specific claim number. Payers act on those quickly.

2. Look for an exception in the plan's own words

   Plans that write limits often write exceptions next to them. If the plan names one and your patient meets it, that is a real appeal with a short argument.

3. Find the next eligible date and use it

   The most useful output of this whole denial. Patients accept dates. Say when the plan covers this again and offer the appointment.

4. Decide about the patient balance

   On a PR line the patient generally owes it. Check whether your contract requires prior written agreement for services beyond a plan limit, because several do.

Codes that get mixed up with 273

Code 273 in dental

Dentistry is the home of the counted benefit, so this code fits it well. Two cleanings a year, bitewings once a period, one crown per tooth per number of years, fluoride to a certain age. All of them produce a 273 when the count is passed.

The replacement clock is the one that catches people

A plan that pays for a crown once every five or seven years counts from the date of the previous one, including one placed by a different dentist. A patient who moved practices will not know, and the front desk cannot see it. Asking the carrier for the last placement date before treatment is the only reliable check.

A count across offices is still a count

Cleanings done elsewhere in the same year use the patient's allowance. This is the most common reason a limit denial surprises everyone, and it is also the easiest to explain to a patient once you have the dates.

Questions people ask about CO-273

Can I appeal a CO-273?

Usually not on the merits, because a limit is a number in the plan. Two things are worth checking: whether the payer counted correctly, and whether the plan writes an exception your patient meets. Ask for the dates behind the count rather than the total, because that is where a duplicate or another provider's claim shows up.

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

A 272 means a condition attached to the service was not met, which documentation can often fix. A 273 means a limit was exceeded, which documentation usually cannot. Same family, opposite prospects.

Does another dentist's work count against my patient's limit?

Yes. Plans count across all providers. A cleaning or a crown done at another office uses the patient's allowance, and neither you nor the patient can see that history without asking the carrier.

Related codes

• CO-272 Guidelines not met. The version documentation can fix.
• CO-119 Benefit maximum reached. Money rather than a count.
• CO-151 The information does not support this many.
• N640 Exceeds the number or frequency allowed. The remark that confirms this.
• M86 Already paid for the same or similar procedure in the time frame.

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