Postpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal with Insertion for October to December 2020

Postpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal with Insertion in Alabama, Georgia and Tennessee for October to December 2020

Palmetto GBA performed service-specific postpayment probe review on HCPCS 66984, Extracapsular Cataract Removal with Insertion. This edit was set in Alabama, Georgia and Tennessee. The results for the probe review for claims processed from October through December 2020 are presented here.

Cumulative Results
A total of 173 providers were placed on edit in Alabama, Georgia and Tennessee combined. A total of 680 claims were reviewed, with 110 of the claims either completely or partially denied resulting in an overall claim denial rate of 16.17 percent. The total dollars reviewed was $380,028.30 of which $59,466.77 was denied, resulting in a charge denial rate of 15.65 percent.

Alabama Results
A total of 54 providers were placed on edit in Alabama. A total of 183 claims were reviewed, with 27 of the claims either completely or partially denied. This resulted in a claim denial rate of 14.75 percent. The total dollars reviewed was $100,910.63 of which $14,431.25 was denied, resulting in a charge denial rate of 14.30 percent. The top denial reasons identified, based on dollars denied:

In order to provide more specific information with regard to the denial reasons identified above, below is a second level of detail obtained during medical review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Georgia Results
A total of 38 providers were placed on edit in Georgia. A total of 188 claims were reviewed, with 23 of the claims either completely or partially denied. This results in a claim denial rate of 12.23 percent. The total dollars reviewed was $109,090.88 of which $12,601.50 was denied, resulting in a charge denial rate of 11.55 percent. The top denial reasons are identified, based on dollars denied.

In order to provide more specific information with regard to the denial reasons identified above, a second level of detail was obtained during medical review. Each claim that was reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Tennessee Results
A total of 81 providers were placed on edit in Tennessee. A total of 309 claims were reviewed, with 60 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.42 percent. The total dollars reviewed was $170,026.79 of which $32,434.02 was denied, resulting in a charge denial rate of 19.10 percent. The top denial reasons are identified, based on dollars denied.

In order to provide more specific information with regard to the denial reasons identified above, a second level of detail was obtained during medical review. Each claim that was reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Reasons and Prevention Recommendations

NOTML — Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

• Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
• Verify that documentation to support the level of service billed is included. Please refer to the Palmetto GBA website for documentation requirements.

BILER — Claim Billed in Error Per Provider

• Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
• For all claims previously billed and denied by medical review, do not resubmit the claims. If you disagree with the decision from medical review, you must submit the appropriate documentation with a completed redetermination request form to the Appeals department. This information can be sent by fax to (803) 699–2427.
• If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam or medical decision-making.)
• If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature

NOSIG — Documentation Lacks the Necessary Provider's Signature

• Verify that all documentation is legibly signed by the rendering physician or nonphysician practitioner
• Verify that an electronic signature meets the CMS signature requirements as listed in the article “Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices” located on our website at www.PalmettoGBA.com/medicare
• Submit a valid Signature Attestation with any documentation that lacks the rendering provider's signature. Do not resubmit altered documentation with late added provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article “Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices” located on our website.

NODOC — Documentation Requested for This Date of Service Was Not Received or Was Incomplete

• Submit all documentation related to the services billed within 45 days of the date on the ADR letter review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
• Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological or laboratory results.
• For claims denied with an M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen or redetermination request form by fax to (803) 699–2427

WRONG — Documentation Received Contains an Incorrect/Incomplete/Illegible Patient Identification or Date of Service

• Review all documentation prior to submission to ensure that it is for the correct patient and date of service
• Ensure that patient identifiers are legible and complete
• Ensure that the complete date of service is clearly and legibly noted on all documentation
• Prior to billing claims, review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate field

296 — Auto Deny — Requested Records Not Submitted Timely           

Reason for Denial
The services billed were not covered because the claim was not submitted or not submitted timely in response to an ADR. When an ADR is generated, the provider has 45 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied, or an overpayment will be collected.

How to Avoid This Denial

• Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
• Submit the medical records as soon as the ADR is received
• Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
• Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department.
• Gather all of the information needed for the claim and submit it all at one time
• Attach a copy of the ADR request to each individual claim
• If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do not use paper clips.
• Do not mail packages C.O.D.; we cannot accept them

More information may be found on the Palmetto GBA website.

The Next Steps
The service-specific targeted medical review edits for Surgical Services — HCPCS 66984, Extracapsular Cataract Removal with Insertion in Alabama, Georgia and Tennessee — will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the redetermination first level appeal form (PDF, 405.3 KB).

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.