CO-45 denial code: charge exceeds the fee schedule or contracted amount

Claim adjustment reason code 45 says: charge exceeds fee schedule, maximum allowable or contracted or legislated fee arrangement. The payer has reduced your billed charge to the amount it allows for the service.

With group code CO, the difference is a contractual adjustment: the practice writes it off and can't bill it to the patient. In network, that is what you agreed to.

Most practices set their charges above any payer's allowed amount, so that no payer pays less than it would have. Every claim then shows a CO-45 for the difference. On its own, a CO-45 means the payer applied its fee schedule.

The adjustment is only right if the allowed amount is right. It isn't when:

• The payer applied the wrong fee schedule, an old year's rates or the wrong locality.
• A contract rate change hasn't been loaded by the payer.
• A multiple-procedure or other payment reduction was applied when it shouldn't have been.
• The payer treated the claim as out of network when you are in network.

Each of these shows up as a normal-looking CO-45 with a smaller payment. Nobody notices unless the payment is compared with what the contract says.

1. Know the expected allowed amount for the code, from your contract or the payer's fee schedule.
2. Compare it with the allowed amount on the payment. The billed charge minus CO-45 should equal the expected allowed amount.
3. If it doesn't, dispute the underpayment with the payer, citing the contract rate.
4. If the same gap repeats across claims, raise it with the payer once for all of them.

CO-45 is decided after the payer answers, so it is checked when the payment arrives.

Claira Health's AI agents follow every denial and every payment until it's resolved, and flag money that comes up short. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

• Every figure is valued at your own contracted rates, never gross charges or an industry average.

How many of your CO-45s are underpayments? Book a 20-minute call and we'll look at a payment file with you.