Claim denials adversely affect a practice’s financial performance, as it means delayed or no payment against the rendered care services. Thus, healthcare facilities strive to keep the denial rate to a minimum either by implementing effective preventive strategies in-house or outsourcing denial management services to a professional revenue cycle management (RCM) company.
Today’s guide is all about understanding the denial code 252, the reasons behind its occurrence, how to avoid it, and steps to address it. So, if you want to manage denials on your own, we recommend you read this guide till the end.
CO 252 Denial Code – Description
A CO 252 denial code identifies that the insurance company requires additional documentation, such as test results or medical records, to adjudicate the claim. For the unversed, ‘CO’ stands for contractual obligation, and denial codes with the Group Code ‘CO’ attached to them are most common in the healthcare industry.
Common Causes of CO 252 Denial Code
Let’s understand the root causes of the CO 252 denial code to effectively mitigate it.
Inadequate Documentation
Missing or incomplete patient insurance information, demographics, or physician notes may lead to this type of contractual obligation denial. If this is the triggering factor, then you will be required to provide the insurance company with additional documentation supporting the medical necessity or appropriateness of the performed service.
Coding Inaccuracies
An outdated or incorrect procedural code can be another culprit for denial code 252. Errors like mistyping codes, inappropriate use of modifiers, or skipping a modifier altogether may trigger the denial and delay reimbursement. Here, you can appeal the denial by correcting the codes and adding the required modifiers.
Referral and Prior Authorization Issues
Many procedures require prior authorization and referral details for clean claim submission. Not including the relevant documentation for these may flag your claim with the CO 252 denial code. In this situation, the payer may ask you to submit evidence of prior authorization or physician referral for successful resolution.
Lack of Medical Necessity
Payers require evidence that the rendered procedure was medically necessary or appropriate for treating the patient’s specific condition. This proof may include lab results, physician notes, or other supporting documents. If the provided documentation fails to justify the performed service’s need, you will receive a CO 252 denial.
How to Prevent Denial Code CO 252?
Here are some strategies to mitigate the risk of CO 252 denial code in your future claims:
Follow Coding Guidelines
Coding guidelines vary across procedures, services, and supplies. Thus, you should carefully review the payer’s specific guidelines for that covered service before submitting a claim. It will help you understand what information and supporting documentation must be attached to the claim to prevent denial code 252.
Train Staff on Billing Best Practices
Another preventive strategy for the CO 252 denial code that you can apply is investing in regular staff training to keep them current on billing best practices, documentation requirements, and coding guidelines. When your staff is well-versed in all these areas, the frequency of errors in claims will reduce, leading to fewer denials and higher reimbursements.
Ensure Comprehensive Documentation
One fail-safe strategy to avoid denial code 252 is to ensure documentation completeness. That is, your medical claim should contain the following:
- Clinical notes
- Diagnosis codes
- All communication records related to prior authorization
- Referral details (if applicable)
- Other supporting documentation justifying the appropriateness and medical necessity of the procedure
- Correct procedural codes that align with diagnosis codes
- Appropriate modifiers specifying the procedure’s complexity
Conduct Regular Internal Audits
Performing internal audits is a great way to get insights into issues and gaps in your medical billing workflow that lead to a higher volume of denials, including the CO 252 denial code. The information gathered through audits can be used to train your staff in areas where they are lacking and create fool-proof strategies to optimize the claim submission process.
Leverage a Robust Claims Management System
Implement an electronic claims management system with built-in checks to flag errors in coding and detect missing documentation. As a result, there will be fewer denials when issues are resolved before claims are submitted. Besides, this system can help you effectively manage and track claims.
How to Resolve Denial Code CO 252?
When you receive the CO 252 denial code, the first step should be to review the denial details, including the remittance advice, and look for any included Remittance Advice Remark Codes (RARCs) or Remark Codes that may or may not be ALERTS. These codes will help you understand what additional documentation is required by the payer to reprocess the claim and release the payment. Moreover, the RARCs indicate that the medical claim can be corrected and resubmitted.
Your second step should be to collect all the necessary documentation, such as the patient’s complete medical record, lab test reports, physical assessment reports, doctors’ referrals, and more.
In the third step, you should verify that all attached documentation is complete and justifies the appropriateness and medical necessity of the rendered care services for claim adjudication.
The fourth step in addressing the denial code 252 involves resubmitting the claim with all the required information and supporting evidence.
Besides, you should also proactively monitor the claim status and follow up with the payer to ensure it is properly processed and approved. Thus, you can say that claim tracking and monitoring is the fifth step in addressing the CO 252 denial code.
List of Common Remark Codes
RARCs provide valuable insight into what triggered the CO 252 denial and what information is needed by the insurance company to process the medical claim. A careful review of these codes will enable you to facilitate the payer with the necessary documentation to mitigate the risk of further denials or payment delays.
Below is the list of the most common RARCs associated with denial code 252:
- N479 – It indicates that the required Explanation of Benefits (EOB), Medicare Secondary Payer, or Coordination of Benefits information is missing.
- N710 – It specifies that the notes are missing.
- N712 – It identifies that the submitted claim does not contain the summary.
- N714 – It highlights that the required lab or assessment report is missing from the claim.
- N716 – It indicates a missing chart.
Bottom Line
We discussed the CO 252 denial code and the common reasons that trigger it, including missing documentation, the lack of medical necessity, coding errors, and issues with prior authorization. Plus, we explained what steps you can take to address this denial for successful resolution.
You can implement the preventative strategies we have shared to steer clear of this denial code in the future. To sum it up, these strategies include leveraging a claim management system, training your staff, performing regular internal audits, and ensuring comprehensive documentation and compliance with coding guidelines. With all this information, if you still find it difficult to manage denials, outsource medical billing to a reputed firm like MediBill MD to plug revenue leaks.
