As a reminder, providers and office staff should adhere to industry standards when submitting medical documentation for claims reconsiderations. CCA would like to refer providers and staff to the following guidelines.
Unlisted Procedure Codes
- Confirm that there is not already an existing procedure code for the service you are submitting an unlisted procedure code for.
- Do not submit modifiers with an unlisted procedure code.
- Ensure you are submitting an explanation to justify why an unlisted procedure code is being used.
- “Submitting records for unlisted procedure 99999” does not justify the rationale for use of the unlisted procedure.
- Please underline the portion of the report that identifies the test or procedure associated with the unlisted procedure code. It must be legible and clearly marked.
- Please refer to the unlisted procedure code payment policy for more information:
- Massachusetts: Payment Policies
- Rhode Island: Payment Policies
Increased Procedural Services (Modifier 22)
- Documentation descriptively detailing increased intensity, time, or technical difficulty
- Documentation containing details on the physical and mental effort required (beyond the normal scope of the procedure)
- Significant trauma that is extensive enough to complicate the procedure
- The procedure is significantly more complex than described for the submitted CPT or HCPCS code, and there is not another, more appropriate code that describes the additional work or complexity involved
- Please refer to the Increase Procedural Services (Modifier 22) payment policy for more information:
- Massachusetts: Payment Policies
- Rhode Island: Payment Policies
Missing Documentation
When submitting claims reconsiderations, please submit medical documentation to support the service(s) appealed. Insufficient, illegible, and missing medical documentation will result in denials of appeal requests. This includes missing invoices for durable medical equipment (DME) and specialty drugs.
Modifier 57
When submitting claims reconsiderations for Modifier 57, please append where the initial decision to perform the surgical procedure is made. This should be done the day of or the day before an evaluation and management service.
- Type of Procedures: Procedure assigned a 90-day global surgery period
For additional policy guidance, including clinical and medical necessity guidelines, please visit:
- Massachusetts: Policies and guidelines
- Rhode Island: Policies and guidelines
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