Postpayment Service-Specific Probe Results for Surgical Services, Extracapsular Cataract Removal with Insertion for April through June 2021

Postpayment Service-Specific Probe Results for Surgical Services — Extracapsular Cataract Removal with Insertion — in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on CPT 66984, Extracapsular Cataract Removal with Insertion. 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 1267 claims were reviewed, with 265 of the claims either completely or partially denied, resulting in an overall claim denial rate of 20.92 percent. The total dollars reviewed was $769,148.63, of which $157,043.78 was denied, resulting in a charge denial rate of 20.42 percent. Overall, there were a total of 73 auto-denied claims in the region. 

North Carolina Results
A total of 726 claims were reviewed, with 186 of the claims either completely or partially denied. This resulted in a claim denial rate of 25.62 percent. The total dollars reviewed was $432,543.48, of which $111,023.36 was denied, resulting in a charge denial rate of 25.67 percent.The top denial reasons were identified, based on dollars denied:

South Carolina Results
A total of 74 claims were reviewed, with eight of the claims either completely or partially denied. This resulted in a claim denial rate of 10.81 percent. The total dollars reviewed was $44,079.13, of which $4,929.04 was denied, resulting in a charge denial rate of 11.18 percent. The top denial reasons were identified, based on dollars denied:

Virginia Results
A total of 341 claims were reviewed, with 41 of the claims either completely or partially denied. This resulted in a claim denial rate of 12.02 percent. The total dollars reviewed was $216,606.15, of which $24,008.48 was denied, resulting in a charge denial rate of 11.08 percent. The top denial reasons were identified, based on dollars denied:

West Virginia Results
A total of 126 claims were reviewed, with 30 of the claims either completely or partially denied. This resulted in a claim denial rate of 23.81 percent. The total dollars reviewed was $75,919.87, of which $17,082.90 was denied, resulting in a charge denial rate of 22.50 percent. The top denial reason was identified, based on dollars denied:

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 website at www.PalmettoGBA.com for documentation requirements.
   

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
   

NOSIG — Documentation Lacks the Necessary Provider Signature

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

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

• 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 of 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)
   

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
   

The Next Steps
The service-specific postpayment medical review edits for Surgical Services — CPT 66984, Extracapsular Cataract Removal with Insertion — 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 Part B Appeals web page. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.