Postpayment Service-Specific Probe Results for Ambulance Services (Emergent), Basic Life Support for April through June 2021

Postpayment Service-Specific Probe Results for Ambulance Services (Emergent), Basic Life Support in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code A0429 – Basic Life Support, Emergency Transport. 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 764 claims were reviewed, with 162 of the claims either completely or partially denied, resulting in an overall claim denial rate of 21.20 percent. The total dollars reviewed was $278,022.36, of which $56,946.42 was denied, resulting in a charge denial rate of 20.48 percent. Overall, there were a total of 49 auto-denied claims in the region. 

North Carolina Results
A total of 91 claims were reviewed, with 12 of the claims either completely or partially denied. This resulted in a claim denial rate of 13.19 percent. The total dollars reviewed was $33,238.90, of which $4,405.07 was denied, resulting in a charge denial rate of 13.25 percent. The top denial reasons identified and number of occurrences based on dollars denied are:

South Carolina Results
A total of 65 claims were reviewed, with 30 of the claims either completely or partially denied. This resulted in a claim denial rate of 46.15 percent. The total dollars reviewed was $22,971.87, of which $10,560.30 was denied, resulting in a charge denial rate of 45.97 percent. The top denial reasons identified and number of occurrences based on dollars denied are:

Virginia Results
A total of 320 claims were reviewed, with 62 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.38 percent. The total dollars reviewed was $119,445.25, of which $22,692.88 was denied, resulting in a charge denial rate of 19.00 percent. The top denial reasons identified and number of occurrences based on dollars denied are:

West Virginia Results
A total of 288 claims were reviewed, with 58 of the claims either completely or partially denied. This resulted in a claim denial rate of 20.14 percent. The total dollars reviewed was $102,366.34, of which $19,288.17 was denied, resulting in a charge denial rate of 18.84 percent. The top denial reasons identified and 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
   

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 LCDs and NCDs page on Palmetto GBA's website.
   

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 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 a 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.
   

ASAVA — Alternative Services Were Available and Should Have Been Utilized

• Prior to billing, ensure that the appropriate HCPCS code is used
• Ensure that the appropriate modifier (GZ or GA) is used for billing claims for non-emergent or non-medically necessary runs when the patient has been informed in advance that the service is expected to be denied by Medicare as not reasonable and necessary.
• Include all necessary supporting medical documentation if required for submissions
   

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
   

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.
   

ATCCF — Transportation Is Only Covered to the Closest Facility That Can Provide the Necessary Care

• Ensure that the appropriate modifier (GZ or GA) is used for billing claims for non-emergent or non-medically necessary runs when the patient has been informed in advance that the service is expected to be denied by Medicare as not reasonable and necessary
• Ensure that documentation supports medical necessity of destination
   

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 log to the medical review department. For more information refer to the CMS Medicare Learning Network (MLN) Matters article MM6698: Signature Guidelines for Medical Review Purposes
• 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.
   

NOPSC — No Physician Certification Statement Submitted in the Medical Record
Review documentation prior to submission to ensure that a complete signed certification statement is included.

The Next Steps
The service-specific targeted medical review edits for Ambulance Services (Emergent): HCPCS Code A0429 – Basic Life Support, Emergency Transport 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.