Additional supporting documentation must be submitted with claims that contain certain modifiers, including:
- CPT modifier 22: requires a concise statement that explains the nature of the 'unusual service'; may also require additional supporting documentation, such as an operative note or procedure note
- CPT modifier 24: may require supporting documentation in addition to the ICD-9 code to demonstrate that the Evaluation & Management (E/M) service is unrelated to a surgery
- CPT modifier 52: requires a concise statement that explains the nature of the 'reduced service'; may also require additional supporting documentation, such as an operative note or procedure note (exception: ophthalmic biometry, or A-scans)
- CPT modifier 53: requires a concise statement as to why it was medically necessary to discontinue the procedure; may also require additional supporting documentation, such as an operative note or procedure note
Claim submission:
- Submit the 'concise statement' in Loop 2300, or 2400, NTE, 02. Fax additional supporting documentation, along with the EDI Fax Cover Sheet:
- Ohio: (803) 264-7708
- South Carolina: (803) 264-4963
- West Virginia: (803) 264-7708
- If you are permitted to file paper claims, submit the concise statement and other supporting documentation as attachments to the claims
For complete information about requirements and exceptions for submitting these and other modifiers, refer to the Palmetto GBA Modifier Lookup. Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.