22 - JE Part B
Increased Procedural Services
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
- 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
- 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.
- 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.
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2 and Section 40.4
Last Updated Mon, 24 Oct 2022 19:11:43 +0000