The following information will assist you with the appeals process, and more specifically, provide clarification regarding the appropriate information to submit with appeal requests. Not all appeal requests will require you to submit documentation such as hospital records, procedure reports, lab results, etc. A large majority of appeals result from information that was omitted from the claim when it was originally submitted for processing. Examples include, but are not limited to the following:

• Submission of an incorrect ICD-9-CM diagnosis code.
• Omission of a modifier (76, 77) to indicate a repeat procedure on the same day by the same or different rendering physician.
• Omission of a modifier (78, 79) to indicate related or unrelated surgery within the global period of another surgical procedure.
• Omission of a modifier (59) to indicate a distinct procedural service reported on the same day or during the same session as another service.

There are instances that will require your office to submit supporting documentation at the time of your initial appeal request. Only you can decide which documentation best supports your claim. Please provide all relevant information and documentation at the time the initial appeal is requested. For your convenience, listed below are examples of services for which you may be experiencing denials and are unclear what documentation is needed when requesting an appeal. Many of the services on this list are associated with frequency parameters or diagnosis requirements. This list should be used as a guide to assist your office with the documentation required to process your appeal request as it relates to each of these specialties.

• Abdominal Ultrasound: Ultrasound report, signs and symptoms, documentation indicating the medical necessity of a complete study versus a limited study.
• Anesthesia: Pre-anesthesia Record, Anesthesia Record, Operative Report, Radiology Report and reason for which anesthesia was rendered for a radiology service
• Biofeedback: Progress/Office Notes, History and Physical
• Blepharoplasty: Operative Report, Visual Field Study, and original photo or slide
• Cardiac Rehabilitation Services: EKG Tracing and Documentation of Medical Necessity/Treatment Plan
• Chiropractic Services: Progress/Office Notes for entire year of service and Documentation of Medical Necessity
• Concurrent Care: Records for entire hospital course including Admission Summary, Progress Notes, Order Sheets
• Cosmetic Surgery/Procedures of Questionable Current Usefulness (POQCU): Documentation of Medical Necessity, Operative Report, Admission Summary, History and Physical
• Consultations: Include documentation for a request for a consult from an appropriate source and the need for consultation in the patient's medical record. Also provide, a written report of his findings which is provided to the referring physician.
• Critical Care Service and Other E/M Service on the Same Day: Provider must supply documentation of the hospital or office E/M furnished early in the day at the time the patient did not require critical care and provide the critical care note.
• Extensive/Unusual Services (Modifier 22): Include office records, test results, operative notes, and/or hospital records to substantiate the extenuating circumstance. This information should be included when the original claim is submitted. If this information is not included, processing of your claim will be delayed, or the claim will be denied.
• Holter Monitoring: History and Physical or Consultation Notes, test results for date of service in question and test results for any prior or subsequent dates of service
• Initial Hospital Visits: If a visit is paid to another physician who was not the admitting doctor, provide hospital record indicating that he/she was the admitting physician and the E and M documentation.
• Laboratory Testing: Lab results for date of service, progress note indicating signs and symptoms patient is experiencing.
• MRI and CAT Scan (Global Service) for the same anatomical area of the body on the same day: MRI and CAT Scan Reports
• Nerve Conduction Velocity (NCV) Studies, Electromyography Studies: Patient History, NCV Worksheet or Report of Results of studies, reports for any prior and subsequent studies, if any
• Noninvasive Arterial and/or Vascular Diagnostic Studies: Notes for the date of service in question; notes for studies on prior and/or subsequent dates of service, if any
• Pelvic Ultrasound: Ultrasound report, medical necessity for service, diagnosis, signs and symptoms, documentation of abnormal physical findings.
• Pharmacotherapy: Prescription medication name and dosage regulation, management of medication and observation of response to medication, modification or renewal of medication, effects and side effects and evaluation of electroconvulsive therapy if applicable.
• Physical Medicine and Rehabilitation: Order sheets, plan of care that includes the type, amount, frequency and duration of therapy. Include diagnosis, treatment goals and prognosis, progress notes and therapy treatment.
• Psychotherapy Service: Documentation of type of service, duration of face to face contact (time), modalities and frequencies of treatment, a note for each encounter including diagnosis, functional status, treatment plan, symptoms, prognosis and progress.
• Radiology: Radiology Report with provider, date and time notated
• Reduced Service (Modifier 52): Include office records, test results, operative notes, and/or hospital records to substantiate the reason for reporting a reduced service. This information should be included when the original claim is submitted. If this information is not included, processing of your claim will be delayed or the claim will be denied.
• Removal of Benign Skin Lesions: Documentation of medical necessity for removal, biopsy, and pathology report. A procedure note, physician's physical findings, patient's signs and symptoms.
• Surgery/Co-Surgery/Team Surgery/Assistant Surgery: Operative Report for each surgeon
• Transthoracic Echocardiography: Radiology Report, Office Notes, History and Physical, and Documentation of Medical Necessity
• Two outpatient visits provided on the same day for unrelated problems: Provide documentation that supports that each visit was for unrelated problems.