Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Drug Test def 22 Classes for July through September 2021

Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Drug Test def 22 Classes — in North Carolina, South Carolina, Virginia and West Virginia for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on Diagnostic Services: Drugs of Abuse Laboratory Tests: G0483 — Drug Test def 22+ Classes. 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 168 claims were reviewed with 116 of the claims either completely or partially denied, resulting in an overall claim denial rate of 69.05 percent. The total dollars reviewed was $41,489.51, of which $28,642.72 was denied, resulting in a charge denial rate of 69.04 percent. Overall, there were a total of 46 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 142 claims were reviewed with 101 of the claims either completely or partially denied. This resulted in a claim denial rate of 71.13 percent. The total dollars reviewed was $35,069.59, of which $24,938.92 was denied, resulting in a charge denial rate of 71.11 percent. The top denial reasons were identified, based on dollars denied:

South Carolina Results
A total of 24 claims were reviewed with 15 of the claims either completely or partially denied. This resulted in a claim denial rate of 62.50 percent. The total dollars reviewed was $5,926.08, of which $3,703.80 was denied, resulting in a charge denial rate of 62.50 percent. The top denial reason was identified, based on dollars denied:

Virginia Results
No results were processed for the July through September 2021 period for Virginia.

West Virginia Results
A total of two claims were reviewed with none of the claims completely or partially denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $493.84, of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. There were no denial reasons identified.

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 applicable LCDs, NCDs, and Coverage Articles 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
   

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 applicable LCDs, NCDs, and Coverage Articles for documentation requirements.
   

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
   

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
   

The Next Steps
The service-specific postpayment medical review edits for Diagnostic Services: Drugs of Abuse Laboratory Tests: G0483 — Drug test def 22+ Classes in North Carolina, South Carolina, Virginia and West Virginia, has 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 Part B Appeals web page. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.