Original Effective Date:
08/01/1994
Current Effective Date:
01/01/2015
Please submit the following types of claims and services with the indicated documentation for manual review to determine proper payment levels.
| Claim/Service | Attachment/Documentation |
|---|---|
| Disposable and reusable incontinence products (T4521-T4534, T4536, T4537, T4539-T4544) | Clinical notes |
| Gloves, nonsterile, per 100 (A4927) | Clinical notes |
| Multiple surgeries (more than one surgical procedure performed during same operative session, on same operative site, for the same condition) | Operative report |
| Laboratory procedures billed more than once on the same day by the same provider | Laboratory/pathology reports |
| Critical care (99291-99292) | Critical care notes |
| Neonatal intensive care (99295-99296) | Critical care notes |
| Prolonged physician services (99354-99357) | Critical care notes |
| By-report procedures | Operative report, pathology report |
| Intermediate/complex surgical repairs | Operative report |
| Unlisted/miscellaneous codes | Operative report (surgery) |
| Modifier codes: | |
| -20 Microsurgery | Operative report (for brain surgery only) |
| -22 Unlisted procedure |
Operative report (surgery) Clinical notes (non-surgery) |
| -53 Discontinued procedure | Operative report |
| -62 Co-surgery (percent distribution must be noted) | Operative report |
| -66 Surgical team (percent distribution must be noted) | Operative report |
| -76 Repeat procedure by same physician | Operative report |
| -77 Repeat procedure by another physician | Operative report |
| -78 Return to operating room for related procedure during post-op period | Operative report |
| -82 Assistant surgeon (when qualified resident surgeon not available) | Operating room supervisor ’s certification of nonavailability of intern/resident |
| Sterilizations | Sterilization Required Consent Form 1146 |
| EPSDT | EPSDT Clinical Information Form |
|
Vision - Bifocals for patients under age 40 years - Glasses within 24 months of the last pair due to change in prescription - Trifocal lenses - Tinted or color-coated corrective lenses |
- Medical justification for the bifocals - Previous and current new glasses prescription that documents the change meets the criteria for new glasses - Documentation that the patient is currently using trifocal lenses for job-related purposes - Medical diagnosis that supports the need for tinted lenses |
| TB testing for adults (more than once in a benefit year) | Notation that explains the reason for the second test (i.e. initial test was positive or inconclusive) |
| Medical claims for drugs submitted on a CMS 1500 or UB04 form and billed with HCPCS codes, including all J codes. | NDC code required for all services provided on or after 1/1/19. Please verify that the NDC numbers are valid and submitted in the correct format. |
| Debridement | Operative report |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|