Quick Explanation
Denial code CO-91 occurs when a payer denies a claim because the required written consultation report, detailing the specialist's findings and treatment recommendations, was not received. According to coding guidelines, a consultation service is only complete and billable when a formal written report is shared back with the requesting provider and made available to the payer upon request.
Common Causes for CO-91
Denials with code CO-91 typically happen for the following specific reasons:
- The specialist completed the consultation but failed to document or finalize the formal written report back to the referring physician.
- The consultation report was generated but was not attached to the electronic claim submission or sent to the payer during the initial billing process.
- The documentation failed to clearly identify the three core elements of a consultation: the request for an opinion, the rendering of the service, and the written report of findings.
- A technical or clearinghouse transmission error prevented the electronic attachment (PWK segment) containing the report from linking to the submitted claim.
How to Prevent CO-91 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Establish an automated workflow in the EHR that flags consultation codes and blocks claim submission until the written report to the referring provider is finalized and attached.
- Train clinical and billing staff on the 'Three Rs' of consultation documentation: Request from the referring provider, Render the evaluation, and Report findings back in writing.
- Utilize electronic attachment features within your billing clearinghouse to seamlessly submit the consultative report alongside the initial claim.
- Conduct regular internal audits on consultation claims to ensure a corresponding written report is present in the patient's medical record before billing.
Appeal Letter Template for CO-91
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-91 - Consult report is missing
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code CO-91: "Consult report is missing".
We are writing to appeal the denial of the submitted consultation service under code CO-91. In accordance with AMA CPT guidelines and CMS guidelines regarding consultative services, a consultation requires a written report of findings and recommendations to be prepared and sent to the requesting clinician. We have enclosed the complete, finalized medical record for the encounter on the date of service, which includes the comprehensive consultation report sent directly to the requesting provider. This documentation clearly satisfies the 'Report' requirement of a consultation service, establishing both the clinical necessity and the fulfillment of billing guidelines. We respectfully request that you review the attached report and reverse this denial to process the claim for immediate 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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