Claim Documentation Requirements

Canolith repositioning, HCPCS code S9092. Clinical notes should be submitted if a previous service was billed within six months of the current service or if the diagnosis is other than ICD-9-CM code 386.11.

Chelation therapy, HCPCS codes J0600 and J3520.

Gastrointestinal tract imaging, CPT code 91111. A copy of the clinical notes and the operative report is required.

Irrigation of implanted venous access device for drug delivery systems, HCPCS code 96523. If a separate payment is requested, include a copy of the narrative explaining the rationale.

Polysomnography - Sleep Studies Documentation required if performed more than twice during a 12-month period, of if the diagnosis does not meet the criteria outlined in the policy.

CPAP initiation and management, CPT codes 94660 and 94662. A copy of the sleep study report is required.

Gastric neurostimulator, Category III code 0162T.

Nerve conduction studies, HPCS code S3905. A copy of the history and physical with medications documented is required.

Neurofunctional testing, CPT code 96020.

Temporomandibular joint (TMJ) syndrome. Services rendered to determine the diagnosis are a benefit of HMSA's HMO plans and Federal Plan 87. A copy of the clinical note describing the findings that led to the diagnosis along with any supporting radiology reports must accompany the claim.

Baldness. For services relating to diagnosing the condition, a copy of the clinical note describing the findings that led to the diagnosis along with any supporting documentation must accompany the claim.

Organ Donor Services.

Procuren, HCPCS code S9055.

In addition, HMSA may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is a reasonable basis for believing such investigation is warranted.


Document Content
		HMSA routinely requires submission of clinical records before payment of claims when the claim includes: EVALUATION AND MANAGEMENT Critical care services, CPT codes 99291 and 99292 Prolonged physician services, CPT codes 99354 and 99359 SURGERY Oral Surgery and Interdental Fixation Services - Claim Documentation Requirements By Report Procedures Complex Wound Repairs and Complicated Incisions Cosmetic Procedures - Claim Documentation Requirements Debridement DURABLE MEDICAL EQUIPMENT Durable Medical Equipment Items Requiring CMN or DIF Durable Medical Equipment, Prosthetics and Orthotics Durable Medical Equipment - Claim Documentation Requirements Pathology and Lab Services - Claim Documentation Requirements Services That Require Precertification ANESTHESIA SERVICE Anesthesia Procedures - Claim Documentation Requirements Catheter Placement by Anesthesia Providers - Claim Documentation Requirements Radiation Management - Claim Documentation Requirements Radiology Services - Claim Documentation Requirements SERVICES BILLED WITH SPECIFIC MODIFIER CODES. Modifier Codes 21 and 22 Modifier Code 62 Modifier Codes 78 and 79 MISCELLANEOUS SERVICES Unlisted and Miscellaneous Codes - Claim Documentation Requirements. Canolith repositioning, HCPCS code S9092. Clinical notes should be submitted if a previous service was billed within six months of the current service or if the diagnosis is other than ICD-9-CM code 386.11. Chelation therapy, HCPCS codes J0600 and J3520. Gastrointestinal tract imaging, CPT code 91111. A copy of the clinical notes and the operative report is required. Irrigation of implanted venous access device for drug delivery systems, HCPCS code 96523. If a separate payment is requested, include a copy of the narrative explaining the rationale. Polysomnography - Sleep Studies Documentation required if performed more than twice during a 12-month period, of if the diagnosis does not meet the criteria outlined in the policy. CPAP initiation and management, CPT codes 94660 and 94662. A copy of the sleep study report is required. Gastric neurostimulator, Category III code 0162T. Nerve conduction studies, HPCS code S3905. A copy of the history and physical with medications documented is required. Neurofunctional testing, CPT code 96020. Temporomandibular joint (TMJ) syndrome. Services rendered to determine the diagnosis are a benefit of HMSA's HMO plans and Federal Plan 87. A copy of the clinical note describing the findings that led to the diagnosis along with any supporting radiology reports must accompany the claim. Baldness. For services relating to diagnosing the condition, a copy of the clinical note describing the findings that led to the diagnosis along with any supporting documentation must accompany the claim. Organ Donor Services. Procuren, HCPCS code S9055. In addition, HMSA may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is a reasonable basis for believing such investigation is warranted.
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First published:		06/16/2008