Postpayment Service-Specific Probe Results for Ambulance Services (Emergent) Advanced Life Support, Emergency Transport for January through March 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Codes A0427 — Advanced 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 January through March 2021, are presented here.

Cumulative Results
A total of 155 claims were reviewed, with 55 of the claims either completely or partially denied, resulting in an overall claim denial rate of 35.48 percent. The total dollars reviewed was $66,146.27, of which $8,398.52 was denied, resulting in a charge denial rate of 12.70 percent. Overall, there were a total of 83 auto-denied claims in the region. 

North Carolina Results
A total of 126 claims were reviewed, with 51 of the claims either completely or partially denied. This resulted in a claim denial rate of 40.48 percent. The total dollars reviewed was $53,831.85, of which $8,136.36, was denied, resulting in a charge denial rate of 15.11 percent. The top denial reasons identified and number of occurrences based on dollars denied are:  

South Carolina Results
No results for South Carolina were processed during the January through March 2021 quarter.

Virginia Results
A total of 14 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 7.14 percent. The total dollars reviewed was $6,237.28, of which $70.34 was denied, resulting in a charge denial rate of 1.13 perent. The top denial reason identified and number of occurrences based on dollars denied are:  

West Virginia Results
A total of 15 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 20.0 percent. The total dollars reviewed was $6,077.14, of which $191.82 was denied, resulting in a charge denial rate of 3.16 percent. The top denial reason 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 our website for links to applicable LCD and NCD articles and the E/M Scoresheet Tool.
   

The Next Steps
The service-specific targeted medical review edits for Ambulance Services (Emergent): HCPCS Codes A0427 — Advanced 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 Redetermination: 1st Level Appeal Form (PDF, 386 KB).

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