Postpayment Service-Specific Probe Results for HBO Therapy: January Through March 2021


Postpayment Service-Specific Probe Results for HCPCS Code G0277 — HBO Therapy in North Carolina, South Carolina, Virginia and West Virginia for January Through March 2021

Palmetto GBA performed a service-specific post payment probe review on HCPCS Code G0277— HBO Therapy. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed January through March, 2021, are presented here.

Cumulative Results
A total of 285 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined. 144 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 50.53 percent. The total dollars reviewed was $528,827.62, of which $225,654.86 was denied, resulting in a charge denial rate of 42.67 percent. Overall, there was a total of 22 auto-denied claims in the region. 

North Carolina Results
A total of 136 claims were reviewed, with 61 of the claims either completely or partially denied. This resulted in a claim denial rate of 44.85 percent. The total dollars reviewed was $249,863.19, of which $86,843.19 was denied, resulting in a charge denial rate of 34.76 percent. The top denial reasons were identified, and the number of occurrences was based on dollars denied. 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

47.54%

5D164/5H164

No Documentation of Medical Necessity

29

37.70%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

23

8.20%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

5

4.92%

5D199/5H199

Billing Error

3

1.64%

5D151/5H151

Units Billed More Than Ordered

1


South Carolina Results
A total of 17 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 64.71 percent. The total dollars reviewed was $36,506.41, of which $21,432.01 was denied, resulting in a charge denial rate of 58.71 percent. The top denial reasons were identified, and the number of occurrences was based on dollars denied. 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

72.73%

5D164/5H164

No Documentation of Medical Necessity

8

27.27%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

3


Virginia Results
A total of 74 claims were reviewed, with 29 of the claims either completely or partially denied. This resulted in a claim denial rate of 39.19 percent. The total dollars reviewed was $223,039.47 of which $103,201.01 was denied, resulting in a charge denial rate of 46.27 percent. The top denial reasons were identified, and the number of occurrences was based on dollars denied. 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

37.93%

5D164/5H164

No Documentation of Medical Necessity

11

24.14%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

7

20.69%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

6

13.79%

5D169/5H169

Services Not Documented

4

3.45%

5DTDP/5HTDP

Dependent Services Denied (Qualifying Service Denied Technically)

1

  
West Virginia Results
A total of 58 claims were reviewed, with 43 of the claims either completely or partially denied. This results in a claim denial rate of 74.14 percebt. The total dollars reviewed was $19,418.55, of which $14,178.65 was denied, resulting in a charge denial rate of 73.02 percent. The top denial reasons were identified, and the number of occurrences was based on dollars denied. 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

72.09%

5D164/5H164

No Documentation of Medical Necessity

31

13.95%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

6

9.30%

5D169/5H169

Services Not Documented

4

4.65%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

2


Denial Reasons and Prevention Recommendations

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial

This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to Avoid This Denial

  • Submit all documentation related to the services billed which support the medical necessity of the services
  • A legible signature is required on all documentation necessary to support orders and medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

  • Code of Federal Regulations, 42 CFR — Section 411.15
  • Social Security Act (SSA) — Section 1862(a)(1)(A)
  • Palmetto GBA Local Coverage Determination (LCD), which is available under "Medical Policies" on the Palmetto GBA website
  • National Coverage Determination (NCD), which is available at which is available under "Medical Policies" on the Palmetto GBA website
  • CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
  • The articles below can be located on the Palmetto GBA website using the search feature
  • CMS Medicare Learning Network (MLN) Matters article MM6698 — "Signature Guidelines for Medical Review Purposes"
  • Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying surgery has been denied. For example, the surgical procedure was denied as documentation did not support medical necessity, therefore all other charges cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but is not limited to, the following:

  • All documentation to support orders, documentation of services rendered and documentation of medical necessity for the qualifying services for the date(s) billed

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Section 410.32
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 120

5D920/5H920 — The Recommended Protocol was not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Clear physician’s order with indication of need, dose, frequency and route 
  • Date and time of associated chemotherapy, as applicable
  • Relevant history and physical and/or progress notes
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response, as applicable
  • Stage of treatment, as applicable 
  • Documentation of administration 

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 50
  • Medicare Claims Processing Manual, Publication 100-04: Chapter 17

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid This Denial

  • Submit all documentation related to the services billed
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed

More Information

  • Code of Federal Regulations, 42 CFR — Sections 410.32 and 424.5
  • The article below can be located on the Palmetto GBA website using the search feature
  •  Responding to an Outpatient Therapy Additional Documentation Request (ADR)

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

How to Avoid This Denial
To avoid future denials for this reason:

  • Check all bills for accuracy prior to submitting to Medicare
  • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service/diagnostic test was rendered, and the dates of service billed

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial 

The physician’s orders submitted did not cover all the units billed.

How to Avoid This Denial
To avoid unnecessary denials for this reason, the provider should ensure that the physician’s orders cover all the services to be billed prior to billing Medicare. When responding to an Additional Documentation Request (ADR), ensure that all orders for services billed are included with the medical records.  

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Codes of Federal Regulations, Sections 410.27 and 424.5.
  • CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 90.2


5DTDP/5HTDP — Dependent Services Denied (Qualifying Service Denied Technically)

Reason for Denial
The dependent services will not be covered if the qualifying surgery has been denied.  For example, the surgical procedure was not documented, therefore all other charges cannot be allowed.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but is not limited to, the following:

  • All documentation to support orders, documentation of services rendered and the medical necessity of qualifying services for the date(s) billed

More Information

  • 42 (CFR) Code of Federal Regulations, Section 410.32
  • CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 120

The Next Steps
The service-specific targeted medical review edits for HCPCS Code G0277 HBO Therapy in North Carolina, South Carolina, Virginia and West Virginia 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 Redetermination:1st Level Appeal Form for JM Part A and for JM Part B regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.





Last Updated: 05/05/2021