CIGNA generally requires clinical documentation at the time a claim is submitted to be considered complete or “clean” for the following categories of claims (exceptions noted):
- codes appended with with an assistant surgeon modifier (80, 81, or 82), assistant-at-surgery modifier (AS), or co-surgeon modifier (62) which typically do not require surgical assistance or co-surgeons
- ‘unlisted code’ as defined in the CPT manual (under ‘Unlisted Services and Procedures’)
- codes that are ‘Not Otherwise Specified’ (NOS)
- codes that are ‘Not Otherwise Classified’ (NOC)
- procedures that are potentially cosmetic
- procedures that may be experimental/investigational/unproven
- procedures that are medically necessary for some indications and not for all indications
- services performed in an unexpected place of service, such as office services performed in an outpatient surgery center
- codes appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 53, 59, or 66)
- specified Evaluation & Management (E/M) service code pairs submited with modifier 25 that are disallowed according to a National Correct Coding Initiative (NCCI) Incidental Edit (also called Column 1/Column 2 Code Edits with CMS ‘1’ modifier designations)*
- specified Non-Evaluation & Management (E/M) service code pairs submitted with modifier 59 that are disallowed according to a National Correct Coding Initiative (NCCI) Mutually Eclusive Edit with CMS ‘1’ modifier designations*
