Postpayment Service-Specific Probe Results for ESRD Monthly Capitation Payments (MCP) for April through June 2021

Postpayment Service-Specific Probe Results for ESRD — ESRD Monthly Capitation Payments (MCP) — in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on: CPT Codes 90960–90963. 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 48 claims were reviewed, with 22 of the claims either completely or partially denied, resulting in an overall claim denial rate of 45.83 percent. The total dollars reviewed was $13,433.05, of which $1,408.90 was denied, resulting in a charge denial rate of 10.49 percent. Overall, there were no auto-denied claims in the region. 

North Carolina Results
No results were processed for North Carolina for the period April through June, 2021.

South Carolina Results
No results were processed for South Carolina for the period April through June, 2021.

Virginia Results
A total of 48 claims were reviewed, with 22 of the claims either completely or partially denied. This resulted in a claim denial rate of 45.83 percent. The total dollars reviewed was $13,433.05, of which $1,408.90 was denied, resulting in a charge denial rate of 10.49 percent. The top denial reason identified, and number of occurrences based on dollars denied are:

West Virginia Results
No results were processed for West Virginia for the period April through June, 2021.

Denial Reasons and Prevention Recommendations

DOWNC — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

• Ensure that all documentation to support the level of service billed is submitted for review
• Verify that documentation to support the level of service billed is included. Please refer to our website for applicable LCDs, NCDs, and Coverage Articles for documentation requirements.
   

DNSRP — Documentation Not Signed by the Rendering Provider

• Verify that all documentation is legibly signed by the correct 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
• Submit a valid signature attestation with any documentation that lacks the correct rending 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.
   

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 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)
   

The Next Steps
The service-specific targeted medical review edits for ESRD – ESRD Monthly Capitation Payments (MCP): CPT Codes 90960–90963 — 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). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.