Wiki CO 252 rejection code - what information are they lacking?

[Dina.angelov@gmail.com]

Hi everybody!

This is the first time I'm writing here. I have a strange claim that was denied with CO 252 code and the appeal wasn't successful either. The clinical was attached but they still say that after consideration they don't think that the visit is as complex as they need for 99205 (new patient). Here are they ICD-10s that were billed accordingly:
R10.84 Generalized abdominal pain
R11.2 Nausea with vomiting, unspecified
F41.9 Anxiety disorder, unspecified
F41.0 Panic disorder without agoraphobia

What am I doing wrong?

Thanks!

 

[bmjack22@aol.com]

response

honestly it may be hard to say what medical director is looking for, do your peer to peer before time runs out.

 

[mitchellde]

given the dx codes you have selected, there is not enough complexity in the diagnosis to support a level 5 new patient. there is no relationship between your first two symptoms and your behavioral health diagnosis. what was the reason that this visit needed the complexity of a level 5 new patient encounter? If you had an appeal already then the payer has had the opportunity to review the documentation and still indicates that a level 5 was not medically indicated. perhaps you could post a copy of the encounter note so that we can review it and give you our insight?