When submitting a claim for payment for labs, x-rays or routine tests, what documentation is required in order to avoid having the claim denied by super-op edits for a noncovered diagnosis?

A. A covered diagnosis should be initially submitted on the claim. If a covered diagnosis is not submitted and the claim is sent for an appeal, an additional covered diagnosis can be added to the claim. Documentation submitted should support the added diagnosis. This could include the initial referral with the covered diagnosis on it, a progress note from the physician supporting the covered diagnosis or why the test was being ordered. A letter from the physician after the fact or a face sheet from the hospital with a diagnosis on it is not sufficient and will not support the reason for the test being ordered. Providers should closely review applicable Local Coverage Determinations (LCDs) and/or National Coverage Decisions (NCDs) for covered diagnosis codes before submitting claims for payment to avoid these denials. Q. If an average program day in an outpatient Partial Hospitalization Program (PHP) is between 4 and 6 hours, one hour of those being individual and/or group ...  more