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October 23, 2014 - Updated 01.12.16

Progressive Corrective Action (PCA) Review: Office Visits

The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on office visits throughout the year. The findings from PCA reviews occurring over 2015 are as follows:

  • Failure to meet the key component levels required for the code billed,
  • The documentation failed to support a face-to-face encounter occurred,
  • Medical necessity was not supported,
  • Cloning of medical records
  • Signature guidelines were not met
    • Late and missing signatures
  • "Incident to" guidelines were not met,
  • Guidelines regarding the use of a scribe were not met,
  • Inappropriate use of CPT modifier 25, and
  • Failure to provide medical records.

For more information on Medicare guidelines, including documentation required to process a claim, please refer to:

CMS Internet Only Manual

Fact sheets:

Social Security Act

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