CO-193: Original Payment Decision Maintained

What Does CO-193 Mean?

CO-193 confirms that a contractual adjustment from a previous claim adjudication has been upheld after the provider's appeal or reconsideration request. The payer reviewed the original decision — whether it was a fee schedule reduction, a bundling edit, a coverage exclusion, or another contractual reason — and concluded it was correctly applied. The provider cannot bill the patient for this amount under CO.

When CARC 193 shows up on a remittance, the payer is telling you that a reconsideration, redetermination, or appeal has been completed and the original payment decision stands. This is not a new denial — it is the payer's confirmation that the previous adjustment or denial was reviewed and found to be correct. You will typically see this code after submitting an appeal, requesting a reconsideration, or disputing a prior claim adjudication.

The significance of CARC 193 depends heavily on the group code. Under CO, the payer is maintaining a contractual adjustment — perhaps a fee schedule reduction, a bundling edit, or a coverage exclusion — and the provider must absorb the write-off unless a higher-level appeal is pursued. Under PR, the payer is reaffirming that the patient owes a specific amount (deductible, coinsurance, or non-covered charge) after the provider or patient challenged that determination. In both cases, the original rationale for the adjustment remains unchanged.

Receiving CARC 193 does not necessarily mean the case is closed. Most payer appeal processes have multiple levels, and you may still have the option to escalate. For Medicare, the progression runs from redetermination to reconsideration by a QIC, then to an ALJ hearing and beyond. For commercial payers, check the contract for the number of appeal levels available. The key question is whether you have new clinical documentation, corrected coding, or a different legal argument that was not presented in the initial challenge.

Common Causes

How to Resolve

Determine whether the upheld decision is correct, and if not, escalate to the next available appeal level with new supporting evidence.

1. Review the payer's rationale Read the appeal response to understand exactly why the original contractual adjustment was upheld. Was it a coding issue, a fee schedule matter, or a coverage determination? The answer dictates your next steps.
2. Gather new supporting evidence If you believe the decision is wrong, compile evidence that was not included in the prior appeal — updated clinical documentation, corrected coding, peer-reviewed guidelines, or payer policy references that support your position.
3. Escalate to the next appeal level Submit a higher-level appeal using the payer's formal process. For Medicare, this may mean requesting a QIC reconsideration or an ALJ hearing. For commercial payers, follow the escalation path outlined in your contract.
4. Write off if no further options remain If all appeal levels have been exhausted or no new evidence is available, post the CO-193 adjustment as a contractual write-off in your billing system.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-193:

How to Prevent CO-193

• Submit comprehensive documentation with the initial claim to reduce the likelihood of denial and subsequent upheld appeal decisions
• Track appeal outcomes by payer and denial reason to identify patterns where certain denials are consistently upheld and adjust your billing practices accordingly
• Always include new evidence or arguments in each appeal level — resubmitting the same materials typically results in the same outcome
• Review payer contracts regularly to ensure you understand the specific terms that underpin contractual adjustments, reducing frivolous appeals

General Prevention

• Submit complete and accurate documentation with the original claim to minimize the need for reconsideration
• Maintain thorough records of all payer communications and appeal submissions to build stronger cases if escalation is needed
• Track denial patterns by payer and code to identify systemic issues that lead to upheld denials
• Ensure coding accuracy and compliance with payer-specific guidelines before initial claim submission
• When filing appeals, always include new or additional evidence beyond what was originally submitted

Also Filed As

The same CARC 193 may appear with different Group Codes:

Related Denial Codes