Postpayment Review Results for Definitive Drug Testing for July to September 2024

Published 10/25/2024

Postpayment Review Results for Definitive Drug Testing for Targeted Probe and Educate (TPE) for July to September 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Healthcare Common Procedure Coding System (HCPCS) codes G0480-G0483 for Definitive Drug Testing. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

Cumulative Results

Table 1: Cumulative Results
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
11 4 7 2
Table 2: Cumulative Results
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
427 216 51% $80,689.13 $40,555.47 50%

Probe One Findings

Table 3: Probe One Findings
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe

Providers Non-Compliant Progressing to Subsequent Probe

 Providers Non-Compliant/Removed for Other Reason
N.C. 9 4 5 1
S.C. 2 0 2 0
Va. 0 0 0 1
W.Va. 0 0 0 0
Table 4: Probe One Findings

State

Number of Claims with Edit Effectiveness

Number of Claims Denied

Overall Claim Denial Rate

Total Dollars Reviewed

Total Dollars Denied

Overall Charge Denial Rate
N.C. 357 160 45% $68,969.31 $32,160.04 47%
S.C. 70 56 80% $11,719.82 $8,395.43 72%
Va. 0 0 0% $0.00 $0.00 0%
W.Va. 0 0 0% $0.00 $0.00 0%

Risk Category
The categories for HCPCS codes G0480–G0483 for Definitive Drug Testing are defined as:

Table 5: Risk Category
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for Definitive Drug Testing.

The categories for HCPCS codes G0480 - G0483 for Definitive Drug Testing are defined as: Major 64% and Minor 36%
 
Top Denial Reasons

Table 6: Top Denial Reasons
Percent of Total Denials Denial Code Denial Description Number of Occurrences
53% NOTML Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed 9
47% 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 8

Denial Reasons and 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
     

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 re-open/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
     

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date. 


Was this article helpful?