When to submit claims with clinical documentation or Medical record

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* 

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