22 - JE Part B

Increased Procedural Services

Instructions

Documentation to indicate that the work performed to provide the service was substantially greater then typically required.

• Must support the substantial additional work
• Reason for the additional work
  • Increased intensity
  • Time
  • Technical difficulty of procedure
  • Severity of patient's condition
  • Physical and mental effort required
• Documentation includes separate paragraph titled Unusual Procedure
• Should not be appended to an evaluation and management service

Correct Use

• Report with surgical procedure codes with a 0, 10, or 90-day global period
• Clearly indicate the difficulty of the procedure beyond the norm
• Submit explanation with claim. Additional documentation no longer requested.

Incorrect Use

• Do not use generalized statements, such as:
  • Surgery took an extra two hours
  • This was a difficult surgery
  • Surgery for an obese patient

Special Appeals Process

When submitting the Reconsideration request, include a separate, concise statement explaining the substantial additional work done and the reason for medical necessity for this additional work.

Resource

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2 and Section 40.4