What does denial code CO-47 mean? Claim Adjustment Reason Code 47 read: “This (these) diagnosis(es) is (are) not covered, missing, or are invalid.” It was a diagnosis-related denial, not a fee-schedule reduction. CARC 47 no longer appears on current CARC lists, so if you still see it, the payer is usually using an old code mapping. Today the same problems are reported with more specific codes such as CO-16 with remark code M76, CO-146, CO-167 or CO-11.
Many websites describe CO-47 as “charge exceeds the fee schedule.” That is CARC 45, a contractual reduction. Mixing the two up sends billing teams to check fee schedules when the real problem is the diagnosis on the claim.
Key Takeaways
- CARC 47 = “This (these) diagnosis(es) is (are) not covered, missing, or are invalid.”
- It is about the diagnosis code, not the charge amount. Charge-over-fee-schedule adjustments are CO-45.
- CARC 47 is no longer on current CARC lists. Payers now use more specific codes, listed below.
- “CO” means contractual obligation: the provider, not the patient, carries the adjustment until the claim is fixed.
- Start every fix by checking the ICD-10-CM code for validity on the date of service, specificity and the payer’s coverage policy.
CO-47 vs CO-45: The Common Mix-Up
| Code | Official meaning | What to check |
|---|---|---|
| CARC 47 | This (these) diagnosis(es) is (are) not covered, missing, or are invalid | The ICD-10-CM codes on the claim |
| CARC 45 | Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement | Your fee schedule and payer contract |
Codes Payers Use Now Instead of CARC 47
| Code | Meaning | Typical fix |
|---|---|---|
| CO-16 + M76 | Claim lacks information; remark M76 = missing, incomplete or invalid diagnosis or condition | Add or correct the diagnosis and resubmit |
| CO-146 | Diagnosis was invalid for the date(s) of service reported | Use the ICD-10-CM code valid on that date of service |
| CO-167 | This (these) diagnosis(es) is (are) not covered | Check the payer policy; appeal with documentation if the coverage criteria are met |
| CO-11 | The diagnosis is inconsistent with the procedure | Link the procedure to the diagnosis that supports it |
| CO-50 | Not deemed a medical necessity by the payer | Appeal with clinical documentation |
See our guides to CO-16, CO-11 and other common claim denial codes.
Common Causes of Diagnosis-Related Denials
- Missing diagnosis pointer: the claim line is not linked to any diagnosis in box 24E of the CMS-1500.
- Invalid or deleted code: the ICD-10-CM code was not valid on the date of service. Code sets change every October 1, and some codes change on April 1.
- Not specific enough: a category or subcategory code was billed instead of a complete, billable code.
- Not covered by the payer’s policy: the diagnosis is not on the covered list in the LCD, NCD or commercial policy for that service.
- Diagnosis does not support the procedure: the procedure is linked to the wrong diagnosis on the claim.
How to Fix a CO-47 (or Similar) Denial
- Read the full remittance. Note the CARC and every remark code. The remark code usually points to the exact problem.
- Check the ICD-10-CM code. Confirm it is complete, billable and valid on the date of service.
- Check the link. Make sure each procedure points to the diagnosis that supports it.
- Check the payer’s coverage policy. Compare the diagnosis with the LCD, NCD or commercial policy for the service.
- Correct or appeal. Send a corrected claim when the coding was wrong. Appeal with documentation when the coding was right and the service meets the policy.
- Ask about the code itself. If the payer still sends CARC 47, ask which current reason code applies so your team can track it correctly.
How to Prevent Diagnosis Denials
- Load the current ICD-10-CM code set into your billing system every October and April.
- Use claim-scrubber edits for non-billable and deleted codes, and for LCD/NCD diagnosis lists.
- Code to the highest level of specificity the documentation supports.
- Review diagnosis pointers before every claim is released.
How Steady Medical Billing Helps
Diagnosis denials are usually coding or system problems. Steady Medical Billing’s medical coding services and denial management services correct these claims and fix the code-set and scrubber rules behind them.
Seeing repeated diagnosis denials? Request a free medical billing and coding audit.
Frequently Asked Questions
What does denial code 47 mean?
CARC 47 means “This (these) diagnosis(es) is (are) not covered, missing, or are invalid.” It points to a problem with the diagnosis codes on the claim.
Is CO-47 the same as CO-45?
No. CO-45 means the charge exceeds the fee schedule or contracted amount. CO-47 is about the diagnosis being missing, invalid or not covered.
Is CARC 47 still used?
It no longer appears on current CARC lists. Payers now report these problems with codes such as CO-16 with remark M76, CO-146, CO-167 or CO-11.
Can I bill the patient for a CO-47 denial?
No. The CO group code means the adjustment is the provider’s responsibility. Correct the claim or appeal instead.
