Postpayment Service-Specific Probe Results for Ambulance Services (Emergent): Basic Life Support for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on Ambulance Services (Emergent): HCPCS Code A0429 — Basic Life Support. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review for claims processed July through September 2021 are presented here.

Cumulative Results 
A total of 250 claims were reviewed with 50 of the claims either completely or partially denied, resulting in an overall claim denial rate of 20.0 percent. The total dollars reviewed was $90,490.58, of which $17,798.33 was denied, resulting in a charge denial rate of 19.67 percent. Overall, there were a total of 143 auto-denied claims in the region. The top denial reasons were identified, and the number of occurrences based on dollars denied are: 

North Carolina Results
A total of 53 claims were reviewed with six of the claims either completely or partially denied. This resulted in a claim denial rate of 11.32 percent. The total dollars reviewed was $18,999.69, of which $1,925.33 was denied, resulting in a charge denial rate of 10.13 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are: 

South Carolina Results
A total of 35 claims were reviewed with eight of the claims either completely or partially denied. This resulted in a claim denial rate of 22.86 percent. The total dollars reviewed was $12,388.23, of which $2,837.50 was denied, resulting in a charge denial rate of 22.90 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are: 

Virginia Results
A total of 121 claims were reviewed with 23 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.01 percent. The total dollars reviewed was $45,061.24, of which $8,532.58 was denied, resulting in a charge denial rate of 18.94 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

West Virginia Results
A total of 41 claims were reviewed with 13 of the claims either completely or partially denied. This resulted in a claim denial rate of 31.71 percent. The total dollars reviewed was $14,041.42, of which $4,502.92 was denied, resulting in a charge denial rate of 32.07 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are: 

Denial Reasons and Prevention Recommendations

BNSIG — Documentation Received Lacks the Necessary Beneficiary or Authorized Representative Signature

• Review documentation prior to submission to ensure that the proper beneficiary or authorized representative signature is included and is legible
• For illegible signatures, clearly print or type the full name of the owner of the signature
   

NOCRD — Provider Signature Does Not Include the Necessary Provider Credentials

• Verify that 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
• Print or type the rendering provider’s full name below or near the provider’s signature 
• For documentation that contains letterhead including the rendering provider’s full name, ensure that the name is clearly marked or circled to indicate the owner of the signature
• Submit a valid Signature Attestation with any documentation that contains an invalid or illegible rendering provider signature. Do not resubmit altered documentation with late corrected 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.
   

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. Palmetto GBA Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles which are available on our website
   

NODOC — Documentation Requested for This Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make A Reasonable and Necessary Determination as Defined Under Section 1862(A) (1) (A) of The ACT for the Service Billed and This Service Has Been Denied

• 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 a 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/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
   

WRONG — Documentation Received Contains an Incorrect, Incomplete or 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
   

NOSIG — Documentation Lacks the Necessary Provider's Signature

• Verify that all documentation is legibly signed by the rendering physician or nonphysician practitioner
• Verify that 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
• 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.
   

NORUN — Documentation Received Lacks the Necessary Run Report

• Review documentation prior to submission to ensure that a complete legible run report is included
   

The Next Steps
The service-specific postpayment medical review edits for Ambulance Services (Emergent): HCPCS Code A0429 — Basic Life Support in North Carolina, South Carolina, Virginia and West Virginia have been discontinued based on the resumption of the Targeted Probe and Educate (TPE).

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). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.