About Appeals

What Documents are Needed?

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What Documents are Needed?

You are responsible for providing all of the information needed to support payment of your claims. The following information will assist you with the appeals process, and more specifically, provide clarification regarding the appropriate information to submit with appeal requests. 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, additional information will not be requested.

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Medical Records to Support an Appeal

The following are examples of services for which you may be experiencing denials and are unclear of 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.

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Anesthesia

  • Pre-anesthesia record
  • Anesthesia record
  • Operative report
  • Radiology report
  • Reason for which anesthesia was rendered for a radiology service

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Biofeedback

  • Progress/office notes
  • History and physical

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Blepharoplasty

  • Operative report
  • Visual field study
  • Original photo or slide

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Cardiac Rehabilitation Services

  • EKG tracing and documentation of medical necessity/treatment plan

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Chiropractic Services

  • Progress/office notes for entire year of service
  • Documentation of medical necessity

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Concurrent Care

  • Records for entire hospital course including admission summary, progress notes, and order sheets

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Cosmetic Surgery/Procedures of Questionable Current Usefulness (POQCU)

  • Documentation of medical necessity
  • Operative report
  • Admission summary
  • History and physical

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Excision of Lesions

  • Operative report
  • Surgical pathology report

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Extensive/Unusual Services (Modifier 22)

  • Include office records
  • Test results
  • Operative notes
  • 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.

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Holter Monitoring

  • History and physical or consultation notes
  • Test results for date of service in question
  • Test results for any prior or subsequent dates of service

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Laboratory Testing

  • Lab report for date of service in question
  • Lab report for any previous and subsequent dates of service, if any, for the same test

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MRI and CAT Scan (Global Service) for Same Anatomical Area of the Body on Same Day

  • MRI and CAT scan reports

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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

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Noninvasive Arterial and/or Vascular Diagnostic Studies

Documentation that would support the necessity of this testing includes, but is not limited to:

  • Order or intent to order, for each study
  • Relevant medical history
  • Physical examination
  • Pertinent diagnostic studies/results

Other pertinent information (not an all-inclusive list):

  • Discharge notes
  • Consultations
  • Medication records
  • Therapy treatment plan and notes
  • Discharge summary and notes
  • Emergency room visits
  • Physician progress notes

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Physiatry

  • Admission summary
  • Progress notes
  • Order sheets
  • Reassessment

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Radiology

  • Radiology report with provider, date and time notated

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Reduced Service (Modifier 52)

  • Include office records
  • Test results
  • Operative notes
  • Hospital records to substantiate the reason for reporting a reduced service

Note: 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.

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Surgery/Cosurgery/Team Surgery/Assistant Surgery

  • Operative report for each surgeon

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Transthoracic Echocardiography

  • Radiology report
  • Office notes
  • History and physical
  • Documentation of medical necessity

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Two Inpatient E/M Visits or Inpatient E/M Visit and Consult on Same Day

  • Records for hospital course including progress/visit/critical care notes
  • Consult report
  • Admission summary
  • Discharge summary

Not all requests will require you to submit documentation such as hospital records, procedure reports, lab results, etc. A large majority of requests result from information that was omitted from the claim when it was originally submitted for processing. In those situations, a reopening may be requested and/or performed by the MAC to correct the omission or clerical error. Examples include (but are not limited to) the following:

  • Submission of an incorrect ICD-10-CM diagnosis code
  • Omission of a modifier 78 or 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.

Helpful Resources

Log Into NGSConnex
Appeals Timeline Calculator
YouTube Video: Holistic Approach to Avoiding Administrative Burden

Form(s) you'll need:

Appeal Forms