CO 61 denial code
Claim adjustment reason code 61. Often reported as CO 61 or PR 61.
No second surgical opinion on file
Unofficial reference. This is our own plain-English explanation, not the official code text. Payer rules differ. Verify with the payer and the official X12 code list. AlphaPrefix is not affiliated with X12, CMS or any payer. Data last updated .
What 61 means
The payer reduced or denied a surgical claim because its plan required a second surgeon's opinion that was not obtained.
Some plans want a second surgeon to confirm that an elective operation is needed before they will pay in full. When that step was skipped, the payer uses this code to explain the cut or denial.
The payer may point to the specific policy in the service-level policy reference on the 835, so look there first. This requirement is uncommon today and usually tied to particular procedures or benefit plans.
Group codes seen with 61
On a remittance, 61 comes after a group code. These are the ones it is most often reported with:
- CO 61 (Contractual Obligation): The provider's side of the ledger. The reduction comes from the payer contract or a rule the provider has to follow, and the patient normally cannot be billed for it.
- PR 61 (Patient Responsibility): The amount is assigned to the patient. Deductibles, coinsurance and copays are the everyday examples. Whether you can collect it still depends on your contract and the patient's plan.
The payer chooses the group code for each adjustment, so the same reason code can appear with another group code on your remittance. Read the two together. More about group codes.
Common causes
- The member's plan requires a second opinion for this elective surgery and none was documented before the procedure.
- A second opinion was obtained but the payer never received a record of it.
- The second opinion came from a provider the plan does not accept for this purpose.
What to do next
- Read the plan's second opinion rules for this procedure and confirm the requirement applied on the date of surgery.
- If a second opinion exists, send the consulting surgeon's note with a reconsideration request.
- Check the group code to see whether the reduction is assigned to the provider or the patient.
- Add a pre-surgery check for second opinion rules to your scheduling or authorization workflow.
Related codes
Source
Official wording: X12 Claim Adjustment Reason Codes list. The explanation on this page is our own plain-English wording, not the X12 text.
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