“The procedure or service is inconsistent with the patient’s history.” This is the message you’ll see on a Medicare Explanation of Benefits (EOB) with remark code CO-261. As of the date of this publication, neither the Centers for Medicare & Medicaid Services nor the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have formally published any clarification and/or direction on the nature of these denials or how to properly resolve them. However, we can share the written instruction the DME MAC medical directors provided to the American Orthotic and Prosthetic Association (AOPA) about how to handle these denials.
It’s first important to note that prior to this direction from the medical directors, claims with CO-261 denials were unprocessable claims, not denied claims, meaning they did not have appeal rights. Corrections had to be made to the claim prior to resubmitting it for reprocessing. Although Medicare is still using the CO-261 remark code, it will now be denied with appeal rights, allowing the supplier to submit a written redetermination with supporting documentation to justify payment for the claim in question.
