Quick Explanation
Denial code CO 98 occurs when a payer determines that the performing, ordering, or referring provider's registered specialty or credentialing taxonomy does not match the requirements necessary to bill or order the specific service. This often happens when payers enforce strict specialty-specific medical policies or when there is a mismatch in the provider's enrollment data. Consequently, the insurance company denies the claim because they do not recognize the billing provider as qualified or contracted under the required specialty for that clinical service.
Common Causes for CO 98
Denials with code CO 98 typically happen for the following specific reasons:
- The billing provider's registered taxonomy code or contracted specialty does not match the payer's credentialing requirements for the specific CPT or HCPCS code billed.
- The ordering or referring physician's specialty is not permitted to order the specific service under the payer's national or local coverage determinations (NCD/LCD).
- An incorrect or outdated National Provider Identifier (NPI) taxonomy code was submitted on the claim form (Box 33b on the CMS-1500).
- In a multi-specialty group practice, multiple providers of different specialties billed services on the same day for the same patient, causing a conflict because the payer's system failed to recognize them as distinct specialties.
How to Prevent CO 98 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Verify and routinely update provider enrollment profiles and taxonomy codes with all contracted payers and the National Plan and Provider Enumeration System (NPPES).
- Review payer-specific coverage guidelines and medical policies prior to performing specialized procedures to ensure the provider's specialty is authorized to perform or order the service.
- Utilize appropriate modifiers, such as Modifier 25 or Modifier 59, when multiple providers of different specialties within the same group practice render distinct services to the same patient on the same day.
- Implement front-end clearinghouse edits that cross-reference billed CPT codes against the billing provider's registered specialty/taxonomy to catch mismatches before submission.
Appeal Letter Template for CO 98
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: CO 98 - Multi-specialty denial code
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code CO 98: "Multi-specialty denial code".
We are writing to appeal the denial of this claim under code CO 98. Pursuant to CMS Medicare Claims Processing Manual Chapter 12, Section 30.6, and AMA CPT guidelines, physicians in the same group practice who are in different specialties may bill and receive payment for distinct services provided to the same patient on the same day. The services billed under CPT code [Insert CPT Code] were medically necessary and fell entirely within the licensed scope of practice and credentialed specialty of Dr. [Insert Provider Name]. The submitted clinical documentation clearly supports the medical necessity of the service and demonstrates that the provider is fully qualified and credentialed to perform this procedure. We respectfully request that you review the attached medical records, update your records to reflect the correct provider specialty alignment, and reprocess this claim for full payment.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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