Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Column Chromatography, Mass Spectrometry for April through June 2021

Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Column Chromatography/Mass Spectrometry in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on: CPT Code 82542 — Column Chromatography/Mass Spectrometry. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review for claims processed April through June, 2021, are presented here.

Cumulative Results 
A total of 27 claims were reviewed with 26 of the claims either completely or partially denied, resulting in an overall claim denial rate of 96.30 percent. The total dollars reviewed was $770.88, of which $746.79 was denied, resulting in a charge denial rate of 96.88 percent. Overall, there were no auto-denied claims in the region. 

North Carolina Results
One claim was reviewed, and it was either completely or partially denied. This resulted in a claim denial rate of 100.0 percent. The total dollars reviewed was $48.18, of which $48.18 was denied, resulting in a charge denial rate of 100.0 percent. The top denial reason was identified, and number of occurrences based on dollars denied are:

South Carolina Results
A total of 21 claims were reviewed, with 20 of the claims either completely or partially denied. This resulted in a claim denial rate of 95.24 percent. The total dollars reviewed was $602.25, of which $578.16 was denied, resulting in a charge denial rate of 96.0 percent. The top denial reason was identified, and number of occurrences based on dollars denied are:

Virginia Results
A total of four claims were reviewed, all of which were either completely or partially denied. This resulted in a claim denial rate of 100.0 percent. The total dollars reviewed was $96.36, of which $96.36 was denied, resulting in a charge denial rate of 100.0 percent. The top denial reason was identified, and number of occurrences based on dollars denied are:

West Virginia Results
A total of one claim was reviewed, and it was either completely or partially denied. This resulted in a claim denial rate of 100.0 percent. The total dollars reviewed was $24.09, of which $24.09 was denied, resulting in a charge denial rate of 100.0 percent. The top denial reason was identified, and number of occurrences based on dollars denied are:

Denial Reasons and Prevention Recommendations

NOTMN — 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 applicable LCDs and NCDs on our website.
   

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 JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
• 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
   

296 — Auto Deny: Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

How to Avoid This Denial

• Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
• Submit the medical records as soon as the Additional Development Request (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 Additional Development Request (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. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
• Gather all the information needed for the claim and submit it all at one time
• Attach a copy of the Additional Development Request (ADR) request to each individual claim
• If responding to multiple Additional Development Requests (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 individually identifiable and bound securely 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

• CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 34 (PDF, 109.36 KB)
• CMS Internet-Only Manual (IOM), Pub100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2 (PDF, 606 KB)
   

The Next Steps
The service-specific targeted medical review edits for Diagnostic Services: Drugs of Abuse Laboratory Tests: CPT Code 82542 — Column Chromatography/Mass Spectrometry 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 the JM Redetermination: 1st Level Appeal form (PDF, 223 KB) regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.