Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. Documentation required with the claim is a concise statement and operative report which is either entered in Item 19 of the CMS-1500 claim form for paper claims or submitted with an electronic claim via the fax attachment process. Failure to submit the appropriate information results in a denial of the claim. Claims submitted with CPT modifier 22 are reviewed on an individual basis. Additional reimbursement allowance will be dependent on the documentation.
Noridian pays claims with the CPT modifier 22 at the established fee schedule rate. Providers may appeal for additional payment with sufficient documentation demonstrating the work performed was substantially greater than typically required and explains why the surgery was unusual.
When appealing:
- Redetermination requests require a separate, concise statement explaining the necessity for additional reimbursement be included.
- Need operative report or separate letter
- Medical Review addresses each request individually with no assurance of additional payment
| Treatment Description | CPT/Modifier |
|---|---|
| Pharyngolaryngectomy, with radical neck dissection; with reconstruction | 31395 22 |
Resource
Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.2 “Billing Requirements for Global Surgeries” – Unusual Circumstances at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/bp104c12.pdf
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