Quick Explanation
Denial code CO-82 indicates that the payer rejected the claim because the initial evaluation or treatment was not performed by a qualified physician. This commonly arises in 'incident-to' billing setups where a physician must conduct the first visit to establish the plan of care, or under specific payer policies requiring an MD or DO for the initial encounter.
Common Causes for CO-82
Denials with code CO-82 typically happen for the following specific reasons:
- Billing an initial evaluation under a supervising physician's NPI when the service was performed independently by a non-physician practitioner (NPP) without establishing a prior physician plan of care.
- Payer-specific policies that mandate the initial diagnostic evaluation or consultation must be completed exclusively by an MD or DO.
- Incomplete or missing co-signatures and documentation from the directing physician on the initial evaluation report.
- Failure to meet CMS 'incident-to' guidelines, which require the physician to initiate the service and remain actively involved in the course of treatment.
How to Prevent CO-82 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Require a licensed physician to conduct and document the first face-to-face encounter to establish the initial plan of care before delegating subsequent visits to NPPs.
- Implement system-wide billing edits to verify provider taxonomy and ensure initial evaluations are billed under the correct rendering provider NPI based on payer-specific rules.
- Train clinical and administrative staff on 'incident-to' billing requirements and payer policies regarding who can perform initial consultations.
- Ensure all NPP-conducted initial evaluations are thoroughly reviewed, co-signed, and supported by documenting the supervising physician's physical presence or direct involvement.
Appeal Letter Template for CO-82
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: CO-82 - The initial evaluation/treatment was not conducted by a physician
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code CO-82: "The initial evaluation/treatment was not conducted by a physician".
We are appealing the denial for code CO-82, as the medical documentation demonstrates that the service meets all applicable billing and clinical guidelines. The initial evaluation was performed in compliance with CMS 'incident-to' guidelines and state scope of practice laws, with direct involvement and supervision by the directing physician. The supervising physician established the initial plan of care, reviewed the clinical findings, and co-signed the encounter notes, establishing a valid physician-patient relationship. Accordingly, the service satisfies the requirements for reimbursement, and we respectfully request that this denial be overturned and the claim processed for payment.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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